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.
Pre-pregnancy wt: 145 lbs.
# prenatal visits:
Recreational Drugs OR Alcohol Use During Pregnancy:
½ pack per day
Planned Pain Management
Childbirth Classes: Y/N
Yes, after administration of epidural
28 Week Rhogam:
Sickle Cell Screen:
Glucose Screen/ 3hr GTT:
Any special labs obtained
Please see lab results on pg. 10
(spontaneous/ elective) 1/1
1 death at 1 month of age due to SIDS
Describe each preg.
Delivery Type (NSVD, LFD, Vacuum, CS, SAB, TAB
Living with patient:
M/8lbs., 4 oz.
M/7 lbs., 8 oz.
M/6 lbs., 8 oz.
MEDICAL HISTORY: (Note do not leave blanks)
(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.
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:
Kidney stones/Lithotripsy 04/2009, Elective abortion 9/2012
HISTORY OF ANEMIA:
HISTORY OF PICA OR AN EATING DISORDER:
HISTORY OF ABUSE OR DOMESTIC VIOLENCE: (Past or present) Cont.
HISTORY OF PSYCHIATRIC TREATMENT:
ANY PHYSICAL OR LEARNING DISABILITIES:
LIST PRESCRIBED MEDICATIONS
Please see medications list