FERRIS STATE UNIVERSITY

DEPARTMENT OF NURSING
OBSTETRIC HISTORY & PHYSICAL EXAM FORM
Student Ann Puruleski Date July 2, 2013
Please review GUIDELINES FOR NURSING HISTORIES before beginning.
BIOGRAPHICAL DATA
A. Pt. init MLA A!e 23 DOB 3-23-1991 Re"i!i#n Catholi Ra$e Cauasian
!. Ma%ita" &tatu& '$(e$) #ne* Sin!"e Marrie" #e$arate" %i&ore" 'i"o(e"
C. Nea%e&t %e"ati+e,&u--#%t -e%&#n '%e"ati#n&(i- #n".* Mother
%. !)*+, #-C*AL .*#/-)0
A. /(e%e e0-"#.ed 'al1art O$$u-ati#n #tu"ent
B. Hi!(e&t edu$ati#n .igh #hool %i$lo1a
CURRENT PREGNANCY
A. E1-e$ted date #2 de"i+e%. January 2, 2013 43 1onths $regnant5 G%a+ida 1 Pa%a 0 A3 0
B. T.-e #2 $(i"d3i%t( -%e-a%ati#n 6atural hil"birth (ith e$i"ural, "oes not (ant Cesarean
C. Date "a&t &een 3. D% July 10
th
, 2013
D. A""e%!ie&,&en&iti+itie& #easonal Allergies
E. S-e$ia" -%#3"e0& t(i& -%e!nan$. and t%eat0ent 6o $roble1s (ith this $regnany.
F. La3#%at#%. a&&e&&0ent 'i2 )n#4n*
B"##d t.-e 7nkno(n, states her 1e"ial reor"s 1ight sho( this.
R( 7nkno(n
Fat(e%5& 3"##d t.-e 7nkno(n
R( 7nkno(n
Ane0ia6 7nkno(n, but "enies being ane1i or ha&ing a history of ane1ia.
G. Nu%&in! a&&e&&0ent
P%e7-%e!nant /t 138 P%e&ent /t9 130 4.as been stresse" an" eating 1ore5 Ht 8 feet, 2
inhes
G. Min#% di&$#02#%t& '$(e$) a"" t(at a--".*
Moo" s(ings 6oturia Pain 4(here5
%ys$areunia : !akahe ;aginal "isharge
: ,atigue Leg ra1$s 6u1bness or s(elling of feet, fingers, ankles
;ariosities Consti$ation *thing of skin or &ul&a
: *nso1nia ,re<uent urination -ther9
: .eart !urn An=iety
.a&e you ha" or been e=$ose" to a 1a>or infetion? 4'hen5 6o
4'hat5
IV. PAST HEALTH AND MENSTRUAL HISTORY
4'rite in this s$ae $ertinent infor1ation relate" to resi"ual or hroni illness.5
.as asth1a
.er 1enstrual history is >ust onsists of a $ast of ha&ing regular $erio"s, starte" $erio"s at 11
years ol".
La&t X7%a.& n# X7%a.&8 3ut (ad an u"t%a&#und T.-e 7ltrasoun"
/(at 0edi$ati#n& and +ita0in& a%e .#u ta)in! and 4(.6 Prenatal &ita1ins, iron
su$$le1ents, an" foli ai". /hat@s (hat she (as tol" to take. Me"iations inlu"e asth1a 1e"iine
suh as Albuterol an" A"&air
V. PAST CONTRACEPTIVE HISTORY
-ral *7% Aels B ,oa1s )hyth1
6or$lant : Con"o1s %+P- Pro&era
A. P%e+i#u& P%e!nan$. Hi&t#%.
%-! #e= !irth (eight Pre1C,/C#tillbirth Li&ing
6o $re&ious. - - - -
- - - - -
- - - - -
- - - - -
B. P%e+i#u& $(i"d%en 4it( -%#3"e0& a2te% 3i%t(6 E1-"ain 6o $re&ious $regnanies.
C. P%#3"e0& 4it( -%e+i#u& -%e!nan$ie& 'e1$e&&i+e +#0itin!8 0u"ti-"e 3i%t(&8 e1$e&&i+e 4t.
!ain8 $"#&e". &-a$ed -%e!nan$ie&8 et$.* E1-"ain9 6o $re&ious $regnanies.
D. P%#3"e0& 4it( -%e+i#u& "a3#%& and,#% de"i+e%ie& 'e1tended "a3#% -e%i#d&8 e1$e&&i+e
3"eedin!8 a3n#%0a" 2eta" -#&iti#n8 et$.* E1-"ain 6o $re&ious $regnanies.
E. P#&t-a%tu0 -%#3"e0& '&u37in+#"uti#n8 in2e$ti#n8 e1$e&& 3"eedin!8 3"adde%8 et$.*
E1-"ain 6o $re&ious $regnanies.
;*. DIET ASSESSMENT
N#. #2 0ea"& -e% da. 3, if she re1e1bers to eat 6o. of snaks $er "ay9 3, snaks beause of
bore"o1.
F"uid inta)e -e% da. Can of $o$, an" a liter of (ater. #he kno(s it@s a liter sine her (ater
bottle hol"s a liter.
Pia9 %enies any ra&ings out of the or"inary. Cra&es hoolate bars.
Peuliarities 4soial-ultural, religious, eono1i, et.5
T.-i$a" Dai". F##d Inta)e in 9:7(% -e%i#d '&a0-"e*
B%ea)2a&t Lun$( Dinne% Sna$)&
,oo" A1ount ,oo" A1ount ,oo" A1ount ,oo" A1ount
/oast 2 slies #ou$ 1 bo(l #teak About 9oD %oritos 2 bo(ls
Juie 2 u$s A$$le 1 large ,ries 2 han"fuls !anana 1
#altines 8 or E *e rea1 1 big bo(l
Choolate 1 bar
NUTRITION LIMITATIONS
/(at d# .#u $#n&ide% t# 3e .#u% (ea"t(. 4ei!(t6 138
D# .#u eat at "ea&t ; 0ea"& a da.6 'hen she re1e1bers to
A%e .#u #n a &-e$ia" diet? 6o, she eats (hat * (ant.
D# .#u ta)e 2#"i$ a$id6 0es.
D# .#u (a+e $u%%ent #% -a&t -%#3"e0 4it( an eatin! di&#%de%? 6o $ast history.
D# .#u (a+e an. denta" -%#3"e0&6 %enies "ental $roble1s.
/(en 4a& .#u% "a&t $(e$) u-? July 10
th

D# .#u (a+e an. +i&i#n -%#3"e0&6 #he (ears ontats
Can .#u (ea% 4it(#ut -%#3"e0&6 0es, she has goo" hearing, $asse" (his$er test.
D# .#u (a+e an. &-ee$( -%#3"e0&? 6o s$eeh $roble1s, s$eaks learly.
D# .#u (a+e an. "ea%nin! -%#3"e0&6 6o learning $roble1s.
D# .#u (a+e an. -(.&i$a" "i0itati#n&6 6o $hysial li1itations.
FEARS,ANXIETIES ABOUT PREGNANCY AND PARENTING
Pe%&#na" Hea"t( /hat she (on@t lose the baby (eight one she "eli&ers.
Pe%&#na" Sa2et. %enies fears, feels safe.
Feta" C#nditi#n #he (ants a healthy baby, an" is slightly ner&ous
Ea%". P%e!nan$. L#&&9 #he is (orrie" about a 1isarriage ha$$ening
P%e!nan$. C#0-"i$ati#n& 6ot too (orrie" sine she hasn@t ha" any yet.
H#&-ita" #he is only ner&ous about the hos$ital if she has to go before her "ue "ate
beause she "oesn@t (ant to ha&e a $re1ature baby
Su%!e%. 6o fears, >ust "oes not (ant a esarean
Ane&t(e&ia 6o fears
Pe%inata" L#&& #he is (orrie" about losing the baby
La3#%,De"i+e%. An=ious for the $ain that o1es (ith gi&ing birth.
In2ant I""ne&& An=ious about ho( to "eal (ith a sik infant
In2ant Atta$(0ent 6ot an=ious, she an@t (ait to bon" an" hol" the baby
Pa%entin! S)i""&
A. Pe%$e-ti#n and )n#4"ed!e #2 -%e!nan$. and de"i+e%. 'in $"ient5& #4n 4#%d&*
F* a1 e=ite" to ha&e a baby an" be a 1o1. *@1 not sure (hat all (ill ha$$en "uring the
"eli&ery. * ha&e been trying to rea" books (hen * ha&e ti1e, an" * really (ant to atten" a
birthing lass or so1ething of the sortG
B. Attitude t#4a%d -%e!nan$.
F* a1 really e=ite" to beo1e a 1other. *t@s been so1ething * ha&e been looking for(ar" to
e&er sine * foun" out * (as $regnant. * (as ner&ous at first, but no( * a1 1ore rela=e" the
1ore * rea" about (hat to e=$et, an" (hat 1y 1o1 an" frien"s ha&e tol" 1e.G
C. <ue&ti#n& a&)ed 3. 0#t(e%7t#73e
F*s it nor1al to (orry about (hat oul" ha$$en?G
F%o $eo$le usually (ait till they "eli&er to "ei"e on a na1e?G
F*s it nor1al to be (orrie" about falling? *@1 going to be $regnant "uring the (inter so * a1
ner&ous for the ie.G
/OR=,SCHOOL ACTIVITIES EXPOSURE
Ha+e .#u e1-e%ien$ed t(e "#&& #2 a $#74#%)e% and,#% 2%iend at 4#%) #% &$(##"?
%enies any loss
Ha+e .#u 3een t(%eatened %e$ent". at 4#%) #% &$(##"6 %enies being threatene"
Ha+e .#u 3een in+#"+ed in an a%!u0ent #% 2i!(t at 4#%) #% &$(##"6 %enies any
argu1ent
Ha+e .#u %e$ent". $(an!ed >#3&6 6o
Ha+e .#u %e$ent". $(an!ed &$(##"6 6o
<uit &$(##"? 6o
D# .#u u&e (ea+. e?ui-0ent6 6o
D# .#u 4#%) "#n! (#u%&6 6o
D# .#u d# (ea+. (#u&e4#%)6 6o
D# .#u #2ten &tand 2#% ;@ 0inute& #% 0#%e at a ti0e6 0es, (hen she is leaning
D# .#u #2ten "i2t 0#%e t(an 9@ -#und&6 0es, (hen leaning
D# .#u (a+e -%#3"e0& $"i03in! &tai%&6 %enies any $roble1 li1bing stairs
D# .#u -"a. &-#%t&6 6o
D# .#u %ide in a $a% 0#%e t(an A (#u% a da.6 -asionally (hen "oing erran"s
D# .#u (a+e a di&a3i"it. t(at "i0it& a$ti+it.6 6o
A%e .#u e1-#&ed t#
Paint t(inne%& #% #+en $"eane%&6 6o
St%#n! $"eane%&6 -nly if bleah ounts an" house leaners
Cat "itte%6 0es, she has one at
Me%$u%. #% "ead6 6ot that she is a(are of
Ce%a0i$&8 &tained !"a&&8 #% >e4e"%. 0a)in! -%#du$t&6 0es, her 1o1 1akes
>e(elry on oasion
Ha+e .#u eaten %a4 #% un$##)ed 0eat? 0es, she has ha" sushi, but not reently.
D# .#u 4ea% .#u% &eat 3e"t6 0es, states she (ears a seatbelt
H#4 0an. &e1ua" -a%tne%& (a+e .#u (ad in t(e -a&t .ea%? 1
A%e .#u n#4 u&in!,ta)in! #% (a+e .#u e+e% ta)en,u&ed (a%d d%u!&6 6e&er ha&e
/(i$( #ne'&*6 6one
A0#unt -- ,re<ueny --
H#4 0an. $i!a%ette& d# .#u &0#)e dai".? %oes not s1oke Any 1arihuana? 6o
D# #t(e%& &0#)e a%#und .#u6 6o
H#4 0u$( a"$#(#"i$ 3e+e%a!e d# .#u d%in) -e% da.,4ee)6 #tates she has not "rank sine she
foun" out she (as $regnant, states she "i"n@t really "rink $re&ious to her $regnany
HOUSEHOLD SOCIAL SUPPORT RESOURCES
H#4 0an. $(i"d%en d# .#u $a%e 2#% in .#u% (#0e6
A!e& 6one
D# .#u $a%e 2#% a 2a0i". 0e03e% 4it( a di&a3i"it.6 6o
D# .#u (a+e a &e%i#u& i""ne&&6 6o
Re$ent #% -"anned 0#+e6 6o
D# .#u 2ee" &"ee-. #% ti%ed a "#t6 0es
D# .#u 2ee" &a2e 4(e%e .#u "i+e6 0es
D# .#u #% an.#ne in .#u% (#u&e e+e% !# t# 3ed (un!%.6 6o
D# .#u (a+e an. -%#3"e0& t(at )ee- .#u 2%#0 (ea"t( $a%e a--#int0ent&? 6o
D# .#u (a+e 2a0i". 4(# 4i"" (e"- .#u? 0es, 1any relati&es ha&e offere" her hel$
D# .#u (a+e 2%iend& .#u $an $#unt #n 4(en .#u need (e"-6 0es, $lenty of frien"s
A%e .#u n#t !ettin! a"#n! 4it( #% a%!uin! 4it( .#u%
Pa%tne% 0es they are getting along, no arguing
Pa%ent 0es they are getting along, no arguing
F%iend& 0es they are getting along, no arguing
C(i"d 6o arguing beause she has no hil"ren
Ot(e% --
D# .#u (a+e a $a% #% a$$e&& t# t%an&-#%tati#n6 0es, o(ns her o(n ar
D# .#u (a+e a$$e&& t# a te"e-(#ne6 0es, she has a ell $hone
D# .#u %e$ei+e
F##d Sta0-& 0es, has a$$lie" for '*C benefits
TANF,/e"2a%e 6o
He"- 4it( C(i"d Ca%e 6o hil"ren right no(
He"- 4it( (#u&in! 6o
/IC .as a$$lie" for '*C
'I a0 addin! t(at &(e 0a. n#t (a+e 3een $#02#%ta3"e an&4e%in! t(e&e
?ue&ti#n& &in$e &(e (e&itated 3e2#%e &(e an&4e%ed t(e07Ann5
INFORMATION ON BABY5S FATHER
D# .#u )n#4 2#% $e%tain 4(#0 t(e 2at(e% #2 t(e 3a3. i&6 0es
I2 .e&8 4(at i& t(e a!e #2 t(e 3a3.5& 2at(e%6 23
I& t(e 3a3.5& 2at(e% (e%e 4it( .#u t#da.6 6o, he (as not $resent "uring this
H#4 "#n! (a+e .#u )n#4n t(e 3a3.5& 2at(e%? A fe( years, 3 or 3
I& t(e 3a3.5& 2at(e% (a--. a3#ut .#u% -%e!nan$.6 0es, she states he is e=ite"
D# .#u $u%%ent". "i+e 4it( t(e 3a3.5& 2at(e%? 0es
A%e .#u 0a%%ied t# t(e 3a3.5& 2at(e%6 6ot 1arrie", together but not 1arrie"
I& t(e 3a3.5& 2at(e% $u%%ent". 0a%%ied t# &#0e#ne e"&e6 6o
D#e& t(e 3a3.5& 2at(e% (a+e $(i"d%en n#t in t(e (#0e6 6o hil"ren
I2 .e&8 (#4 0an. $(i"d%en d#e& (e (a+e6 6one
/(at i& (i&,(e% a!e6 6o hil"ren
H#4 "#n! (a+e .#u )n#4n .#u% -a%tne%6 A fe( years, 3 or 3
I& (e,&(e (a--. a3#ut .#u% -%e!nan$.6 0es, she states he is e=ite"
D#e& .#u% -a%tne% (a+e $(i"d%en n#t in t(e (#0e? 6o, it@s the father so it@s the sa1e as
abo&e
I2 .e&8 (#4 0an. d#e& (e,&(e (a+e6 6one, as state" abo&e.
LIFE STRESSORS MENTAL HEALTH VIOLENCE,ABUSE
/a& .#u% -%e!nan$. -"anned? 6o
D# .#u 4ant t# -a%ent t(i& $(i"d6 0es
D# .#u (a+e en#u!( 0#ne. t# -a. 2#% 2##d8 (#u&in!8 & 3i""&6 0es, bet(een her an"
hi1 they see1 to ha&e enough 1oney
Ha+e .#u %e$ent". e1-e%ien$ed an e1t%e0e". &t%e&&2u" e+ent '(#u&e 2i%e8 t#%nad#8
deat(*6 6o, "enies a stressful e&ent
D# .#u 2ee" #+e%4(e"0ed8 &ad8 (#-e"e&&8 #% "#&t -"ea&u%e in t(e t(in!& u&ua"".
en>#.ed6 %enies these feelings.
A%e .#u (a+in! an. -%#3"e0& &"ee-in!6 6o
Ha+e .#u %e$ent". t(#u!(t a3#ut &ui$ide6 6e&er
Ha+e .#u e+e% atte0-ted &ui$ide6 /(en? 6e&er
Ha+e .#u e+e% 3een dia!n#&ed 4it( a 0enta" (ea"t( $#nditi#n? 6o
Ha+e .#u 3een (#&-ita"iBed 2#% a 0enta" (ea"t( $#nditi#n6 6o
Did .#u attend #% $u%%ent". attend 0enta" (ea"t( $#un&e"in!? 6o
A%e .#u e+e% a2%aid #2 .#u% -a%tne%6 6e&er
In t(e "a&t .ea%8 (a& an.#ne at (#0e (it8 )i$)ed8 -un$(ed8 #% #t(e%4i&e (u%t .#u6 6o
In t(e "a&t .ea%8 (a& an.#ne at (#0e #2ten -ut .#u d#4n8 (u0i"iated .#u #% t%ied t#
$#nt%#" 4(at .#u $an d#6 6o
In t(e "a&t .ea%8 (a& an.#ne at (#0e t(%eatened t# (u%t .#u6 6o
Ha+e .#u in t(e -a&t #% %e$ent". 3een a +i$ti0 #2
Ra-e,Se1ua" A&&au"t6 6o
Pa&t Re$ent
Menta" A3u&e6 6o
Pa&t Re$ent
C%i0e Vi$ti06 6o
Pa&t Re$ent
Ha+e .#u e+e% 3een in+e&ti!ated 2#% (u%tin! #% ne!"e$tin! a $(i"d6 6o, she has no
other ki"s
BABY5S FATHER OR CURRENT PARTNER IN THE HOME
D#e& t(e 3a3.5& 2at(e% #% .#u% $u%%ent -a%tne% u&e
T#3a$$#6 6o
A"$#(#"6 -n oasion, but not often es$eially no( that she is $regnant he
"oesn@t "rink
Ma%i>uana6 6o
C#$aine6 6o
IV D%u!&6 6o
Met(6 6o
I& (e 3i7&e1ua"6 6o
D#e& (e (a+e 0u"ti-"e -a%tne%&6 6o, >ust her.
I& t(e 3a3.5& 2at(e% #% .#u% $u%%ent -a%tne% e0-"#.ed6 0es
VII. PHYSICAL ASSESSMENT
Gene%a" A--ea%an$e 'DO NOT -ut C!##dD #% /NL*
#he a$$ears to be lean, no bo"y o"or, her hair is urle", she has 1akeu$ on, her nails are
"one so it a$$ears that she takes are of herself. .er lothes are lean, they "on@t see1 to
ha&e holes in the1. #he is "resse" in light lothing sine it has been &ery hot out. #he has
$ale skin, so * aske" to 1ake sure she is (earing sunsreen to $rotet her fro1 burning.
#he 1akes eye ontat, "oes not ha&e any bruises that * an see. .er $ulse (as H0, her
heart an" lungs soun"e" lear, she ha" ati&e bo(el soun"s.
Edu$ati#na" Need&,Inte%+enti#n&
-n the basis of your assess1ent, list at least T/O nursing "iagnoses for your $atient, inter&entions 41in 3Cnursing "iagnosis5, assess1ents for
eah nursing "iagnosis, an" the rationale for your ations. Please ha&e su$$orting e&i"ene fro1 the literature for your $lan. !e sure your
assess1ent an" inter&entions orres$on" to your 6ursing %iagnosis.
Nu%&in! Dia!n#&i& Ne$e&&a%. A&&e&&0ent&,Inte%+enti#n& Rati#na"e
Re2e%en$e&
A)A%*6A )7!)*C ,-) -! -) 6+'!-)6 A##+##M+6/
Be"#4 E1-e$tati#n& Need& I0-%#+e0ent Meet& E1-e$tati#n& E1$e-ti#na"
A. A&&e&&0ent 418 $oints5
Assess1ent has I12 blank
s$aes, has $oor analysis
420 $oints5
Assess1ent has 9-12 blanks
428 $oints5
Assess1ent has 8-H blank
s$aes, analysis nee" to be 1ore
in "e$th
430 $oints5
Assess1ent has no blank s$aes
an" e=e$tional analysis
B. Nu%&in! dia!n#&i& 40 $oints5
%oes not o1$lete the are $lan
418 $oints5
Chooses ina$$ro$riate nursing
"iagnoses base" on the
assess1ent
412 $oints5
Chooses 1-2 a$$ro$riate nursing
"iagnoses base" on the
assess1ent
420 $oints5
Chooses 3 a$$ro$riate nursing
"iagnoses base" on the
assess1ent
C. Inte%+enti#n& 40 $oints5
%oes not ha&e any inter&entions
418 $oints5
.as hosen ina$$ro$riate nursing
inter&entions
412 $oints5
Chooses 2-3 a$$ro$riate nursing
inter&entions for eah "iagnosis
420 $oints5
Chooses 3 or 1ore a$$ro$riate
nursing inter&entions for eah
nursing "iagnosis
D. Rati#na"e 2#% inte%+enti#n& 40 $oints5
%oes not ha&e any rationales for
inter&entions
418 $oints5
#tate" ina$$ro$riate rationales
for nursing inter&entions
412 $oints5
#tate" a$$ro$riate rationales for
nursing inter&entions for eah
"iagnosis
420 $oints5
*n-"e$th "isussion of the
nursing inter&entions for eah
"iagnosis (ith e&i"ene-base"
su$$ort outsi"e of te=tbooks
E. G%a00a%8 &-e""in!8 &
$"a%it. #2 idea&
42 $oints5
I10 errors in gra11ar or
s$ellingJ i"eas are not learly
$resente"
48 $oints5
K10 errors in gra11ar or
s$ellingJ i"eas are al1ost al(ays
learly $resente"
42 $oints5
K8 errors in gra11ar or s$ellingJ
i"eas are learly $resente"
410 $oints5
APA for1at is e=ellentJ no
errors in gra11ar or s$ellingJ
i"eas are learly $resente"