RN Program
CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN
LABOR AND DELIVERY
STUDENT NAME: Robin Rickards CLINICAL SITE/UNIT: SOH/L & D CLINICAL DATE: 01/13/15
ALLERGIES (DRUGS, FOODS, ENVIRONMENTAL, LATEX): NKDA
PRIMARY LANGUAGE: English RELIGIOUS AFILLIATION: None SPEAKS AND UNDERSTANDS ENGLISH WELL: Yes
ABLE TO READ ENGLISH: Yes
GROWTH/DEVELOPMENT : ERICKSON According to Erickson, pt. falls in the “young adulthood” phase, with title being, “Intimacy vs. Isolation.” Patient is in this stage based on age only. Patient is single and relies on her mother and sister to help with children. She has no contact with the fathers of her other children or the one she is currently pregnant with.
DEMOGRAPHICS:
Patient initials:
Single
Recreational Drugs OR Alcohol Use During Pregnancy:
Marijuana
Smoking Y/N
Amount:
½ pack per day
Breast/Bottle
Breast
Planned Pain Management
Yes/Epidural
Special Diet
No
Childbirth Classes: Y/N
No
Fall risk
Yes, after administration of epidural
PRENTAL LABS:
Blood Type/RH:
A +
28 Week Rhogam:
Y/N/NA
No
RPR:
NR
Hgb/Hct:
9.7d/dL/30 %
WBC:
12.7 K/uL
Triple Screen:
Not documented
Sickle Cell Screen:
No
HIV/HBSAG:
Negative
Glucose Screen/ 3hr GTT:
Not documented
Rubella Titer:
Positive
GC:
Not documented
Chlamydia:
Negative
Herpes (HSV)
Negative
HPV
Negative
Any special labs obtained
Please see lab results on pg. 10
OBSTETRIC HISTORY:
G:
6
T:
3
P:
2
AB:
(spontaneous/ elective) 1/1
L:
2
Multiple Gestations:
6
Stillbirths/
Neonatal Deaths:
1 death at 1 month of age due to SIDS
Describe each preg.
Year:
Delivery Type (NSVD, LFD, Vacuum, CS, SAB, TAB
Weeks gestation
Sex/Weight:
Pain Mgt.:
Living with patient:
Maternal/Birth/
Neonatal Complications:
1
2001
NSVD
39
M/8lbs., 4 oz.
None
Deceased
None
2
2007
NSVD
40
M/7 lbs., 8 oz.
Epidural
Yes
None
3
2012
NSVD
39
M/6 lbs., 8 oz.
Epidural
Yes
None
4
5
MEDICAL HISTORY: (Note do not leave blanks)
CHIEF CONCERN:
(Reason for coming to the hospital)
NOTE: If pt. is a healthy female without any medical condition simply put her medical Dx. as IUP (intrauterine pregnancy at ____ weeks gestation.
CURRENT MEDICAL HISTORY: MEDICAL DIAGNOSIS THAT CAN BE AFFECTED BY PREGNANCY/LABOR/BIRTH OR CAN NEGATIVLEY EFFECT PREGNANCY Example: diabetes, hypertension, heart disease etc.
Medical complications associated with pregnancy such as preterm labor, PIH, Gestational Diabetes, Placenta Previa, etc.
Medical Diagnosis
IUP at 39 weeks and 2 days gestation
Textbook Clinical Picture
Definition, Signs and Symptoms that should be seen (use citation)
Client’s Actual Clinical Picture
What signs and symptoms your patient actually exhibited.
Premonitory signs and symptoms of labor include: cervical changes, lightening, leg cramps, frequency in urination, low back pain, increased energy, bloody show, and Braxton Hicks contractions (Ricci, 2013.) The patient’s actual clinical picture presents in frequency in urination, low back pain, and Braxton Hicks contraction. Pt. is a scheduled induction.
PAST MEDICAL AND SURGICAL HISTORY:
