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Page 1 of 32
University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
UNIVERSITY OF THE VISAYAS
COLLEGE OF NURSING Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No.: (032) 346-9292
RELATED LEARNING EXPERIENCE WORKBOOK
OBSTETRIC NURSING
Name of Student: _________________________________________
Level: __________________________________________________
Note: To be submitted with clearance at the end of the semester
Rev. 5 05-03-2018
Page 2 of 32
University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
UNIVERSITY OF THE VISAYAS
COLLEGE OF NURSING Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No.: (032) 346-9292
ACKNOWLEDGEMENT
This obstetrical manual is a fruition of the collective efforts of the members of the faculty
of the University of the Visayas College of Nursing. From its inception, formation, verification,
validation and final furnishing of the output, the support and dedication of the faculty members
was unwavering. The authors would like to extend their deep gratitude and appreciation to the
efforts of all the people involved in creating this manual. We hope this manual would provide
better understanding and learning for student nurses in their related learning experience
exposure and enhance their skills using the different nursing theories in their journey towards
competency building.
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
UNIVERSITY OF THE VISAYAS
COLLEGE OF NURSING Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No.: (032) 346-9292
Table of Contents
Content Page
Related Learning Experience Monitoring Sheet 4
Related Learning Experience Attitudinal Scale 5
Patient Centered Nurse’s Record 6
Patient’s Data Profile 7
Head-to-toe Assessment 9
Nursing Systems Review 12
Interpretation of Patient’s Laboratory/ Diagnostic Results 19
Anatomy and Physiology 20
Obstetrical Management 21
Outline of Nursing Management 22
Drug Study 23
Nursing Care Plan 24
Summary Performance Evaluation Achieving Obstetrical Care Competency 25
Glossary 28
References 30
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
UNIVERSITY OF THE VISAYAS
COLLEGE OF NURSING Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No.: (032) 346-9292
RELATED LEARNING EXPERIENCE MONITORING SHEET
Name of Student: ________________________ Level: ________________________
Area: Obstetrical Ward____________________ Date Covered: __________________
AREAS OF EVALUATION GRADE TOTAL WEIGHT COMMENTS
ATTENDANCE 5%
1. Attendance
PROGRESSIVE ASSESSMENT 20%
1. Pre-test
DEPORTMENT 5%
1. RLE Attitudinal Scale
PRACTICAL ASSESSMENT 70%
1. PCNR (30%)
2. RLE Evaluative Record (5%)
3. Group Case Study Conference
(10%)
4. Individual Case Conference (10%)
5. Nursing Procedures (10%)
6. Reflection Journal (5%)
Total
Page 5 of 32
University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
UNIVERSITY OF THE VISAYAS
COLLEGE OF NURSING Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No.: (032) 346-9292
RELATED LEARNING EXPERIENCE ATTITUDINAL SCALE
Name of Student: ________________________ Level: ________________________
Area: _________________________________ Date Covered: __________________
Degree of Performance and Quality Classification:
5- Excellent
4- Above Average
3- Average
2- Needs improvement
1- Poor
AREAS TO BE ASSESSED RATING
1. Shows positive attitude towards role required in the area. 5 4 3 2 1
2. Accepts responsibility to pursue goals in the care of the client. 5 4 3 2 1
3. Demonstrates ability to establish rapport with clients. 5 4 3 2 1
4. Self- directed, motivated and willing to assume task/s assigned. 5 4 3 2 1
5. Requests for assistance when needed and is willing to correct
deficiencies.
5 4 3 2 1
6. Seeks feedback of work accomplished from supervisors and
instructors.
5 4 3 2 1
7. Initiates nursing actions under the supervision of the Clinical
Instructor.
5 4 3 2 1
8. Demonstrates caring and compassionate attitude in client
management.
5 4 3 2 1
9. Accepts values of others without imposing own value system. 5 4 3 2 1
10. Demonstrates respect of clients, supervisors, and peers. 5 4 3 2 1
TOTAL POINTS: _____________________
EQUIVALENT GRADE: _____________________
Page 6 of 32
University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
UNIVERSITY OF THE VISAYAS COLLEGE OF NURSING
Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No.: (032) 346-9292
PATIENT CENTERED NURSE’S RECORD
Name of Student: ________________________ Level: ________________________
Area: _________________________________ Date Covered: __________________
AREAS OF ASSESSMENT POINTS ACTUAL
SCORE
EQ GRADE
I. Patient Data Record, Head-to-toe
Assessment, and Interpretation of patient’s
laboratory/ diagnostic procedures
30
II. Anatomy and Physiology 10
III. Complications of Pregnancy 10
III. Obstetrical Management 10
IV. Nursing Management according to Goals of
Care
10
V. Drug Study 10
VI. Nursing Care Plan 20
100
Total Points
Average Grade
Signature of Clinical Instructor: ________________________________________
Signature over Printed Name of Clinical Instructor
Page 7 of 32
University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
UNIVERSITY OF THE VISAYAS
COLLEGE OF NURSING Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No.: (032) 346-9292
PATIENT’S DATA PROFILE
A. Demographic Profile: (Fill in the basic information needed) 10 pts.
Name of Patient:(Initials only) ____________ Date/Time Assessed: ______________
Date of Birth: _________ Age: _________ Gender:___________
Height: ___________ Weight: ____________
Date & Time Admitted: ___________________________________
Chief Complaint/s: ______________________________________________________
Admitting Diagnosis/ Impression: __________________________________________
Final Diagnosis: ________________________________________________________
Attending Physician: ____________________________________________________
Vital Signs: (Upon Assessment)
Temperature: ___________ PR: _________ RR: __________ BP: ____________
Pain Rating Scale: _______
B. Gynecological and Obstetric History:
Menstrual History:
1. Age of Menarche: _______
2. Last Menstrual Period (LMP): _____________________
3. Menstrual Cycle: ( ) Short: < 28 days ( ) Mid: 28-32days ( ) Long: >32days
( ) Regular ( ) Irregular
4. Duration of menses: ________ days
5. Menstrual Flow ( ) Heavy ( ) Moderate ( ) Light
6. Do you have dysmennorhea during menses? ( ) Yes ( ) No
7. Does bleeding or spotting occur between periods? ( ) Yes ( ) No
Obstetric History:
Gravida: ____ Term: ____ Para: ____ Abortion: ____ Living: ____
Record of Pregnancies
Date of
Delivery
Type of Delivery Duration of
Pregnancy
Place of Delivery
C. Current Obstetrical Data:
Age of Gestation (AOG):____________
Estimated Date of Confinement (EDC):___________________
Prenatal Visit AOG Date of Visit Place
1st
2nd
3rd
4th
5th
6th
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
Medications Taken: ______________________________________________________
______________________________________________________
______________________________________________________
TT Vaccination: ______________________________________________________
______________________________________________________
D. Family History:
( ) Cancer: _________ ( ) Diabetes ( ) Heart Disease
( ) Hypertension ( ) Asthma ( ) Epilepsy
( ) Others: __________________________________________________________
If yes to any, list affected members: ______________________________________
______________________________________
E. Past Medical/ Surgical History:
( ) Arthritis ( ) Kidney Disease ( ) Asthma
( ) Diabetes ( ) Gall Stones ( ) Emphysema
( ) STI’s: ____________ ( ) Liver Disease ( ) Bronchitis
( ) Lung disease including Hepatitis ( ) Tuberculosis
( ) Gastrointestinal disease ( ) Epilepsy ( ) Eating Disorder
( ) High Blood Pressure ( ) Blood transfusions ( ) Surgeries: ______________
( ) Heart Disease ( ) Thyroid Disease ________________
F. Social History:
Do you smoke? ( ) No ( ) Yes; ______________ No. of packs/day_________
Do you drink alcoholic beverages: ( ) No ( ) Yes; Amount consumed_________
Substance abuse: ( ) No ( ) Yes; Frequency___________
Number of sexual partners: _______
Exercise: ( ) No ( ) Yes
G. Current Medications:
Note: If taking maintenance medications
Medication Dose Frequency
H. History of Food and Drug Allergies:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
UNIVERSITY OF THE VISAYAS COLLEGE OF NURSING
Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No.: (032) 346-9292
HEAD-TO-TOE ASSESSMENT
Name of Patient: (Initials only )_________________________ Date /Time Assessed: ______________
Areas to be Assessed Subjective Cue(s)
Findings
Head, Scalp and Hair
Inspect size, shape and contour
Observe scalp
Palpate the head
Face
Inspect face for symmetry
Palpate TMJ
Percuss the sinuses
Listen for temporal artery bruits
Instruct to make faces
Perform touch sensation test
Perform taste test (if needed)
Eyebrows and Eyelashes
Inspect for symmetry and shape
Inspect conjunctiva
Palpate lacrimal apparatus
Eyes
Perform Snellen Test
Inspect sclerae
Perform 6 cardinal fields of gaze
Perform accommodation test
Perform corneal reflex test
Perform pupillary reflex test
Do opthalmoscope exam (if available)
Ears
Inspect for shape and symmetry
Palpate external auricle
Inspect auditory meatus (ear canal)
Do whisper test
Perform Rinne Test and Webber Test (if hearing problem is detected)
Otoscopic exam (if applicable)
Nose
Inspect shape and symmetry
Inspect nostrils one at a time
Palpate nasal bridge
Use modified otoscope to inspect inside of nose
Percuss sinuses
Perform olfaction test ( if pt. complains of smelling problems
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
Mouth and Throat Inspect features of lips Palpate TMJ while pt. opens and closes mouth Inspect oral mucosa
Inspect hard and soft palate
Inspect tonsils and give appropriate grading
Inspect teeth
Palpate side of tongue
Instruct to move tongue with resistance
Neck Inspect neck ( symmetry and presence of
bulges)
Use penlight to check bulges of neck
Palpate carotids one at a time
Auscultate for bruits
Palpate the thyroid
Palpate the lymph nodes in proper order
Check accessory muscles of neck and shoulders
Thorax (Respi.) Inspect quality of respiration Inspect for symmetry and deformity
Move to back and palpate spinous processes
( spine)
Palpate for lung expansion
Perform tactile fremitus
Percuss and check diaphragmatic excursion
Auscultate for breath sounds in correct order
Move to anterior chest and observe for shape and symmetry
Palpate for lung expansion
Perform tactile fremitus test
Percuss chest
Auscultate for breath sounds
Thorax (Cardio.) Inspect apical pulse Palpate apical pulse
Palpate sternoclavicular area, aortic area, pulmonic area, left ventricular area
Auscultate heart right 2nd ICS, left sternal border, 2nd to 5th ICS and apex using diaphragm
Repeat same process using bell
Upper Extremities Inspect hand and arms Do capillary refill test
Palpate radial and brachial pulses
Check sensory function of arm ( touch, pain,
temperature , vibration and position)
Touch discrimation ( steriognosis, graphesthesia, 2pt discrimation, extinction)
Motor function by deep tendon reflex ( biceps, triceps, brachial radialis)
Cerebellar function of arm ( RAM, finger touch, finger to finger localization, finger to nose test)
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
Abdomen Inspect abdomen from rib to symphysis pubis.
Assess bulges (use penlight)
Auscultate abdomen starting at RLQ, LLQ, LUQ
and RUQ
Auscultate for vascular sounds using bell ( aorta, renal, iliac and femoral)
Percuss starting at RUQ moving in counter
clockwise direction
Percuss liver
Percuss stomach at LUQ
Percuss for spleen (turn pt. to right side)
Percuss bladder
Perform light palpation starting RLQ in clockwise manner
Perform deep palpation
Palpate bladder
Palpate kidneys using bimanual technique
Test abdominal superficial reflex
Lower extremities Inspect legs Flex legs and dorsiflex foot
Palpate peripheral pulses ( femoral, popliteal, posterior tibialis, dorsalis pedis,)
Palpate for edema (if present)
Perform sensory test ( light touch, pain,
temperature, vibration and position)
Check DTR (patellar, achilles)
Babinski reflex
Cerebellar test (heel –shin test, gait, tandem
walk, Romberg’s test)
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
UNIVERSITY OF THE VISAYAS
COLLEGE OF NURSING Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No.: (032) 346-9292
NURSING SYSTEMS REVIEW (10 pts)
Name of Patient:_________________________ Date/Time Assessed:______________ (Place an “X” on the findings of your assessment, briefly justify with a narrative discussion, place subjective cues (if applicable), and identify a nursing diagnosis according to the findings of your assessment.)
CARDIOVASCULAR SYSTEM Narrative discussion of cardiovascular system findings: A. Bulging of neck veins ( ) Present ( ) Absent B. Quality of carotid pulsation during palpation (Compare both sides) Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Symmetry: ( ) Symmetrical ( ) Asymmetrical C. Capillary refill time: Nail color: ( ) Pinkish ( ) Pale ( ) Cyanotic Upper extremity (Right): ( ) Immediate to 2 sec. ( ) More than 2 sec. Upper extremity (Left): ( ) Immediate to 2 sec. ( ) More than 2 sec. D. Quality of peripheral pulsation: Brachial Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Symmetry : ( ) Symmetrical ( ) Asymmetrical Radial Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Symmetry : ( ) Symmetrical ( ) Asymmetrical E. Quality of peripheral pulsation: Femoral Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Symmetry : ( ) Symmetrical ( ) Asymmetrical Posterior tibialis Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Symmetry: : ( ) Symmetrical ( ) Asymmetrical Popliteal Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Symmetry : ( ) Symmetrical ( ) Asymmetrical Dorsalis Pedis Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic
Subjective Cues
Nursing Diagnosis
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Symmetry : ( ) Symmetrical ( ) Asymmetrical F. Quality of Apical pulsation (clavicular, subclavicular, apex sites) Clavicular Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Apical Heart Rate (PMI): ___________Bpm ( ) Regular ( ) Bounding ( ) Tachycardic Subclavicular Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Apical Heart Rate (PMI): ___________Bpm ( ) Regular ( ) Bounding ( ) Tachycardic Apex sites Rhythm of pulsation: ( ) Rhythmic ( ) Non-rhythmic Intensity of pulsation: ( ) Regular ( ) Bounding ( ) Weak Apical Heart Rate (PMI): ___________Bpm ( ) Regular ( ) Bounding ( ) Tachycardic Quality of apical pulsation during auscultation (R- Subclavicular, L- Subclavicular, L-2nd - 5th ICS, Apex) Heart sounds: ( ) Regular ( ) Adventitious a. ______Gallops b. ______Murmurs
G.Others Heart Palpitations, increase heart rate ( ) Present ( ) Absent PMIshifts about1.5cm to the left ( ) Present ( ) Absent Blood Physiologic dilutional anemia/ pseudoanemia ( ) Present ( ) Absent physiologic anemia of pregnancy ( ) Present ( ) Absent pulmonic and apical systolic murmurs ( ) Present ( ) Absent supinehypotension, fainting spells ( ) Present ( ) Absent ankleedema ( ) Present ( ) Absent varicosisities ( ) Present ( ) Absent Blood pressure: 1st trimester: ______________ mmHg 2nd and 3rd Trimester: __________mmHg Headache ( ) Present ( ) Absent
RESPIRATORY SYSTEM Narrative discussion of respiratory system findings: A. Observe for quality of respiration: ( ) Eupneic ( ) Dyspneic ( ) Shortness of breath B. Check respiratory rate: __________ cpm C. Observe for anterior view and AP view of chest (Check ratio)
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
( ) Normal ( ) Pectus Excavatum ( ) Pectus Carinatum D. Perform tactile fremitus (Posterior) ( ) Regular ( ) Increased Vibration ( ) Diminished Vibration E. Lung Expansion: ( ) Regular/ Symmetrical ( ) Asymmetrical F. Percuss sound @ lung field ( ) Resonant ( ) Dull ( ) Flat ( ) Tympanic G. Auscultate breath sounds (Posterior and Anterior): ( ) Clear ( ) Adventitious ( ) Wheezing ( ) Crackles ( ) Others: ___________ H. Check presence of cough: ( ) None ( ) Present ( ) Productive ( ) Non-productive I. Other changes: Slight hyperventilcation (SOB): ( ) Present ( ) Absent Nasal congestion ( ) Present ( ) Absent change in voice ( ) Present ( ) Absent epistaxis ( ) Present ( ) Absent edema of nasal mucosa ( ) Present ( ) Absent
Subjective Cues
Nursing Diagnosis
MUSCULOSKELETAL SYSTEM Narrative discussion of musculoskeletal system findings:
A. Mobility: ( ) Ambulatory ( ) Ambulates with assistance or with assistive device ( ) Not ambulatory Observe for gait: ( ) Effortless ( ) Spastic ( ) Waddling ( ) Zigzagging Observe for posture: ( ) Erect ( ) Scoliotic ( ) Lordotic ( ) Stooping B. Presence of musculoskeletal deformity: ( ) None ( ) Present Specify: _____________________ C. Presence of any orthopedic devices: ( ) Cast ( ) Traction ( ) Prosthesis ( ) Others: ________ D. Muscle tone/ strength (Tardieu Scale): ( ) No resistance through passive movement ( ) Slight resistance through passive movements ( ) Presence of clonus at certain angles ( ) Rigid limb and joint E. Range of motion: ( ) Full ( ) Partial F. Presence of pain: ( ) Absent ( ) Present only during ambulation ( ) Present: ________ Pain score ( ) Sprain ( ) Strain ( ) Fracture G. Postural changes
Subjective Cues
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
Lumbosacral curve ( ) Present ( ) Absent Back pains and cramps ( ) Present ( ) Absent Waddling gait ofpregnancy ( ) Present ( ) Absent
Nursing Diagnosis
SENSORY PERCEPTION Narrative discussion of sensory perception findings:
Eyes A. Eyebrows and Eyelids ( ) No structural aberration/ Symmetrical ( ) Drooping of Eyelids ( ) Right ( ) Left ( ) Both B. Conjunctiva ( ) Pinkish ( ) Reddish ( ) Pale C. Sclera ( ) White ( ) Reddish ( ) Yellowish D. Visual Acuity ( ) Normal ( ) Far Sighted ( ) Near Sighted E. Six Cardinal fields of gaze ( ) Normal/ symmetrical ( ) Assymetrical F. Cover/ uncover: ( ) Stable ( ) Unstable G. Corneal reflex: ( ) Aligned ( ) Not aligned/ Not centered H. Pupillary reflex: ( ) PERRLA ( ) non PERRLA Ears
A. External ear: ( ) Symmetrical ( ) Non-symmetrical B. Ear canal: ( ) Patent ( ) Excessive cerumen C. Whisper test: ( ) Receptive ( ) Has difficulty hearing ( ) Non-receptive Weber’s test: ( ) Lateralization ( ) No lateralization Rinne’s test: ( ) + ( ) – Nose A. External structure: ( ) Regular/ symmetrical ( ) Obvious deformity B. Nostrils: ( ) Patent and intact ( ) Obstructive ( ) Excessive secretions C. Sense of smell: ( ) Intact ( ) Has difficulty ( ) Absent
Subjective Cues
Nursing Diagnosis
INTEGUMENTARY SYSTEM Narrative discussion of integumentary system findings:
A. Skin integrity: ( ) Intact ( ) Lesions/ Ulcerations Location: ___________________ ( ) Rashes Location: ___________________ ( ) Bruising Location: ___________________ B. Skin Color: ( ) Regular ( ) Discoloration ( ) Erythema ( ) Cyanosis ( ) Pallor ( )Jaundice ( ) Hyperpigmentation Location: ___________________ Skin Temperature: ( ) Regular ( ) Warm to touch ( ) Cold and clammy C. Skin pinch: ( ) Normal ( ) Delayed
D. Edema: ( ) Absent ( ) Present:
Subjective Cues
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
( ) Non-pitting ( ) Pitting: ( ) +1 ( ) +2 ( ) +3 ( ) +4 E. Others Hyperactive sweat and sebaceous glands Palmar erythema and angiomas Hair and nails- grow faster but becomes thinner and softer
Nursing Diagnosis
GASTROINTESTINAL SYSTEM Narrative discussion of gastrointestinal system findings:
A. Appetite: ( ) Normal ( ) Loss of appetite B. Oral Mucosa: ( ) Pinkish ( ) Pale ( ) Bleeding noted C. Teeth: ( ) Well embedded ( ) Incomplete/ Dental Caries noted D. Bowel Sound: ( ) Normal: 5-15 per minute
( ) Hypoactive: <5 per minute ( ) Hyperactive: >15 per minute ( ) Absent
E. Bowel Movement: ( ) Regular Frequency (Last 24 hours):________ ( ) Loose bowel movement ( ) Constipated
F. Abdominal Pain: ( ) Absent ( ) Present Location:____________________ Rebound tenderness: ( )+ ( )- Board-like abdomen: ( )+ ( )- G. Vomiting: ( ) Absent ( ) Present Frequency (within 24 hours):____________ H. Other Changes: Heartburn (pyrosis) and flatulence: ( ) Present ( ) Absent Low appetite: ( ) Present ( ) Absent Constipation: ( ) Present ( ) Absent Epulis of pregnancy: ( ) Present ( ) Absent Ptyalism: ( ) Present ( ) Absent Hemorrhoids: ( ) Present ( ) Absent Pica: ( ) Present ( ) Absent I.Metabolic Chnages: Edema: ( ) Present ( ) Absent Increased body tempareature ( ) Present ( ) Absent Weight gain: ( ) Present ( ) Absent Fatigue: ( ) Present ( ) Absent
Subjective Cues
Nursing Diagnosis
ENDOCRINE SYSTEM Narrative discussion of endocrinal system findings:
Increase BMR
Slight hyperplasia of the thyroid
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
Increase milk production
Increase HCG: (+) pregnancy tests
Gestational diabetes
Subjective Cues
Nursing Diagnosis
NEUROLOGIC SYSTEM Narrative discussion of neurological system findings:
A. Level of consciousness: ( ) Fully conscious ( ) Lethargic ( ) Stuporous ( ) Comatose B. Coherence: ( ) Coherence ( ) Incoherent C. Orientation: ( ) Oriented ( ) Disoriented D. Mood and affect: ( ) Appropriate ( ) Inappropriate ( ) Flat E. Cerebellar Function (Upper Extremity): Rapid Alternating Movement: ( ) Coordinated ( ) Uncoordinated
Finger to nose: ( ) Coordinated ( ) Uncoordinated Finger-thumb: ( ) Coordinated ( ) Uncoordinated Alternating touch to nose: ( ) Coordinated ( ) Uncoordinated F. Cerebellar function (Lower extremity): Heel-shin test: ( ) Coordinated ( ) Uncoordinated Gait: ( ) Coordinated ( ) Uncoordinated G. Balance: Tandem walk: ( ) Well balanced ( ) Imbalanced Romberg’s test: ( ) Coordinated ( ) Uncoordinated H. Deep tendon reflex:
Site +1 +2 +3 +4
Brachial
Tricep
Patellar
I. Babinski Reflex: ( )+ ( )-
Subjective Cues
Nursing Diagnosis
LYMPHATIC SYSTEM Narrative discussion of Lymphatic system findings:
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
Tonsils: ( ) +1 ( ) +2 ( ) +3 ( ) +4
Lymph Nodes +1 +2 +3 +4
Pre auricular
Post auricular
Occipital
Sub mental
Sub mandibular
Lymph Nodes +1 +2 +3 +4
Tonsillar
Superficial Cervical
Deep Cervical Chain
Posterior Cervical
Supraclavicular
Subjective Cues
Nursing Diagnosis
GENITO-URINARY SYSTEM Narrative discussion of genitourinary system findings:
A. Discharges: ( ) Absent ( ) Present Color: ( ) Bright red ( ) Dark red ( ) Brown/Pinkish ( ) White/ pale yellow
Amount: ( ) Heavy ( ) Moderate ( ) Light Odor: ( ) present ( ) absent
B. Pain/ Itching in genitalia: ( ) Absent ( ) Present C. Bladder: ( ) Normal ( ) Distended ( ) Incontinent D. Urination:
Pain: ( ) present ( ) absent Color: ( ) Amber ( ) Tea colored ( ) Blood tinged ( ) Cloudy ( ) Clear Odor: ( ) present ( ) absent
Frequency: ___________ times ______________mL Glycosuria: ( ) Present ( ) Absent
Lactosuria: ( ) Present ( ) Absent
Subjective Cues
Nursing Diagnosis
REPRODUCTIVE SYSTEM Narrative discussion of reproductive system findings:
A. ANTENATAL
a. Uterine Changes (Hegar’s) b. Braxton Hick’s Contractions c. Amenorrhea d. Cervical changes (Goodel’s)
e. Leucorrhea f. Changes in the breasts
Subjective Cues
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
B. INTRANATAL C. POSTNATAL
a. Breast: ( ) Normal ( ) Engorged b. Uterus: ( ) Normal ( ) Contracted ( ) Fundal Height: ____
Nursing Diagnosis
COPING PATTERN
Any recent changes in patient’s life (job, death, major surgeries, recent abuse, others)?
Identify issues in self image if there is any.
Coping techniques employed in dealing with stress?
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
INTERPRETATION OF CLIENT’S LABORATORY/DIAGNOSTIC RESULTS (Identify and list down all laboratory/ diagnostic results done to patient and fill out indications of such results)
Laboratory Date
Performed
Actual Result Normal Value
(Reference)
Significance of the
Result
Diagnostic
Procedures
Date
Performed
Actual Result Normal Value
(Reference)
Significance of the
Result
Reference:
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
UNIVERSITY OF THE VISAYAS COLLEGE OF NURSING
Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No.: (032) 346-9292
ANATOMY AND PHYSIOLOGY (10 pts) (Label and explain the functions of the affected organ or body part.)
Reference:
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
UNIVERSITY OF THE VISAYAS COLLEGE OF NURSING
Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No.: (032) 346-9292
COMPLICATIONS OF PREGNANCY (10 pts)
Reference:
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
UNIVERSITY OF THE VISAYAS COLLEGE OF NURSING
Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No.: (032) 346-9292
OBSTETRICAL MANAGEMENT (10 pts) (Write the definition and nursing responsibilities for any ideal/actual management) 20 pts.
IDEAL MANAGEMENT ACTUAL MANAGEMENT a. Laboratory Examinations
b. Diagnostic Procedures
c. Treatment
d. Medication
e. Diet
f. Activity/ Exercise
g. Referral
(Note: Please provide additional pages if needed) References:
Page 24 of 32
University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
UNIVERSITY OF THE VISAYAS COLLEGE OF NURSING
Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No.: (032) 346-9292
OUTLINE OF NURSING MANAGEMENT (10 pts)
(Give at least five (5) ideal Nursing Management according to Priority Goals of Care)
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UNIVERSITY OF THE VISAYAS
COLLEGE OF NURSING Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No.: (032) 346-9292
DRUG STUDY (10 pts)
Name of Patient: (Initials only)______________________________________ (Write all the drugs/ medications presently prescribed)
Name of drug Generic and Brand name
Date ordered
Dose, frequency,
route and time
Specific Indication
Classification Mechanism of action Side Effects Nursing Responsibilities
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
UNIVERSITY OF THE VISAYAS
COLLEGE OF NURSING Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No.: (032) 346-9292
NURSING CARE PLAN (20 pts)
Name of Patient: (Initials only) _______________________________________ (Make a nursing care plan from the identified priority nursing problems)
Assessment Nursing Diagnosis Client Goal Nursing Intervention Rationale Outcome Criteria Actual Evaluation S: O:
Scientific Basis:
Reference:
Independent:
Dependent:
Collaborative:
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University of the Visayas College of Nursing- Obstetric Nursing Manual Rev. 05- 05.03.2018
UNIVERSITY OF THE VISAYAS
COLLEGE OF NURSING Gov. M. Cuenco Ave., Banilad, Mandaue City 6014
Tel. No.: (032) 346-9292
SUMMARY PERFORMANCE EVALUATION ACHIEVING
OBSTETRICAL CARE COMPETENCY (In accordance with PRC Board of Nursing Memorandum No. 01 Series 2009)
POSTPARTUM COMPETENCIES Desired Rating
1st RLE 2nd RLE 3rd RLE
I. Safe and Quality Nursing Care
1. Obtain obstetrical and delivery history like problems encountered and managements performed.
2
2. Monitor vital signs and well being` 1
3. Conducts P.E. during postpartum period.
a. Breast Inspect for redness, amount of breast milk
secretions. Palpate for presence of warmth and tenderness.
2
2
b. Uterus Palpate the uterus to check for signs of uterine
atony Massage uterus upon the first sign of uterine
relaxation. Assess for uterine evolution.
2
2
1
c. Bladder Palpate the bladder immediately after the delivery.
If with catheter, check if patient has voided after 6-8 hours from the time the catheter was removed.
2
2
d. Bowel Assess for presence of constipation. Assess for factors that delays bowel movement such
as presence of episiotomy.
1 2
e. Lochia Assess for amount, color and odor. Assess the number of pads used in 4 hours. Assess Lochia:
Every 15 minutes for the first hour Every 30 minutes for the next 2 hours Every 4 hours for the next 24 hours
Every 8 hours until the patient is discharged
2 1 1
f. Homan’s sign 2
g. Episiotomy 2
II. Management of Resources and Environment
1. Utilizes available resources in the unit to manage
patient’s problem like hypo/hyperthermia, keeping uterus firm and well contracted and early ambulation.
2
2. Emphasize the importance of breast milk for the child’s development.
2
III. Health Education
1. Breast Cleanse using plain water only Encourage early breast feeding Teaches different breast feeding positions Teaches to include the whole areola during breast
feeding
2
2. Uterus Teach the patient the normal position of the fundus
postpartum
1
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Assist the patient in palpating her normally contracted fundus and to immediately inform
should there be any signs of uterine relaxation to the medical staff.
2
3. Bladder Educate the patient the importance of urinating 4-6
hours after delivery and prior to palpation of fundal height.
Teach the patient how to promote urination: Soak the hands on tepid/ cold water Let the patient hear running water
Pour warm water over the perineum. Refer to physician if all conservative measures to promote urination fails.
2
2
4. Bowel Educate about the importance of high fiber diet Teach how to increase fluid intake
Use of stool softeners if conservative measures fail
2 1
1
5. Lochia Educate importance of perineal hygiene, amount,
color and odor of lochial discharges to the patient.
2
IV. LEGAL RESPONSIBILITIES
1. Secure informed consent in all procedures 2
2. Document all the assessment/ abnormalities noticed and interventions done during postpartum period.
2
3. Consider legalities of actions in performing both independent
2
V. ETHICO-MORAL RESPONSIBILITY
1. Respect the religious, culture, and ethnic practices of the patient and family.
2
2. Promote empathy and practice patient advocate role in performing postpartum care.
2
3. Ensures safety, privacy, and confidentiality. 2
VI. PERSONAL/ PROFESSIONAL DEVELOPMENT
1. Updates oneself to the latest trends and development in postpartum care.
2
2. Projects professional image of an obstetrical nurse 2
3. Accepts criticism & recommendations 1
4. Perform functions according to standards of care. 2
VII. QUALITY IMPROVEMENT
1. Identifies deviation of practice from standards. 1
2. Recommends corrective & preventive measures for the identified deviations.
2
VIII. RESEARCH
1. Identifies researchable problems related to postpartum
care.
2
2. Initiates a research study on an identified researchable problems
1
3. Participate as a member of a research team in the conduction of a research study.
2
IX. RECORDS MANAGEMENT
1. Document accurately a relevant data about the postpartum client.
2
2. Maintain an organized system of filing and keeping records of the client.
2
X. COMMUNICATION
1. Utilize all forms of communication verbal, non-verbal, and devices appropriately.
2
2. Observe and apply the principles of communication e.g. Listening to the client’s and families queries attentively.
2
XI. COLLABORATION & TEAMWORK
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1. Function effectively as a team player in caring for a postpartum patient/s.
2
2. Establish collaborative relationship with members of the health team and family members.
2
TOTAL 80
When graded RLE’s were performed (Specify academic year and semester):
First Graded RLE: Academic Year________________ 1st Sem._____ 2nd Sem._____ Summer_______
Clinical Instructor: Name_______________________ Signature_______________________________
License Number_______________ Validity:________________________________
Second Graded RLE: Academic Year______________ 1st Sem._____ 2nd Sem._____ Summer_______
Clinical Instructor: Name_______________________ Signature_______________________________
License Number_______________ Validity: ________________________________
Third Graded RLE: Academic Year_______________ 1st Sem._____ 2nd Sem._____ Summer_______
Clinical Instructor: Name_______________________ Signature_______________________________
License Number_______________ Validity: ________________________________
Verified True and Correct: ______________________ License Number: _________________________
(Signature over printed name)
Clinical Coordinator Validity: __________________________________
Academic year graduated: ______________________
_______________________________________ License Number: _________________________
Dean Validity:________________________________
Signature over printed name
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GLOSSARY
Abdomen - belly, tummy
Amniotic fluid - liquid surrounding the fetus in the womb
Amniocentesis - minimal surgical procedure using a very thin needle to get a sample of amniotic fluid for
genetical or biochemical analysis
Alphafetoprotein - a protein produced by all developing babies and present in the mother´s blood. An
increased level may indicate fetal abnormalities (spina bifida…)
Breech - fetus lying in the womb upside down (buttocks down)
Cardiovascular: relating to the heart and blood vessels
Cervix - the neck of the womb, opens during labor to allow the fetus to leave the mother´s body
Contraction - cramp of the uterine muscle leading to the hardening or tightening of the stomach
Diagnostic: of, relating to, or used in diagnosis : used to help identify a disease, illness, or problem.
Dilatation- widening of the neck of the womb (cervix) during labour
Drug: a medicine or other substance which has a physiological effect when ingested or otherwise
introduced into the body
Edema - swelling, commonly in fingers or ankles during late pregnancy
Effacement of the cervix - shortening of the neck of the womb at the beginning of labor
EFM - electronic fetal monitoring (= cardiotocography), monitoring of fetal heart and uterine activity
Engagement - dropping of the fetal head or buttocks into the pelvis a short time before the baby's due
date
Embryo - the unborn baby during the first 8 weeks in the womb
Enema - lavage of lower part of bowel with warm water prior to delivery
Episiotomy - cut of perineum to enlarge the vaginal opening and prevent perineal tearing
Femur - fetal thigh
Fetus - the unborn baby in the womb from week 9 until birth
Fundus - the bottom or base of anything, e.g. the uterus
Gestation - the period of development of the unborn baby from conception until birth
Humerus - fetal arm
Hypertension - high blood pressure (hypotension = low blood pressure)
Induction of labor - artificial triggering of uterine contractions by cervical massage, breaking of water,
medication
Integumentary: comprises the skin and its appendages acting to protect the body from various kinds of
damage, such as loss of water or abrasion from outside. The integumentary system includes hair,
scales, feathers, hooves, and nails.
Laboratory: is a facility that provides controlled conditions in which scientific or technological research,
experiments, and measurement may be performed.
Lochia: the normal discharge from the uterus after childbirth
Myometrium - uterine muscle (the major part of the womb)
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Neurologic: relating to the anatomy, functions, and organic disorders of nerves and the nervous system
Normohydramnios - normal amount of amniotic fluid
Nursing: Nursing encompasses autonomous and collaborative care of individuals of all ages, families,
groups and communities, sick or well and in all settings
Obstetrics - branch of medical science which deals with pregnancy, labor and childbirth
Oligohydramnios - decreased amount of amniotic fluid
Pelvic floor - a hammock of muscles which supports the bowel, bladder and womb
Perineum - part of the female body between vagina and anus
Phenylketonuria - metabolic disease which, when untreated, can harm the development of the baby's
brain
Placenta - the organ which joins the mother with her unborn baby in the womb and which helps the
mother to protect the fetus against the environment
Polyhydramnios - increased amount of amniotic fluid
Pre-eclampsia - serious disease developing mostly in late pregnancy characterised by high blood
pressure, protein in the urine and general swelling
Premature labor - labor which starts between the 24th - 37th weeks of gestation
PROM - premature rupture of membranes (before 37th week or more than 24 hours before the onset of
labor)
Puerperium - time period of six weeks after childbirth necessary for a woman's organism to fully recover
Respiratory: relating to or affecting respiration or the organs of respiration.
Rhesus factor - specific protein on the surface of red blood cells determining rhesus factor positivity
(present) or negativity (absent)
ROM - rupture of membranes, occurs before onset of labor or during the labor
Rubella - german measles, a viral infectious disease which can cause fetal birth defects if acquired during
the first three months of pregnancy
Sensory/ Perception: occurs in organisms capable of performing neurophysiological processing of the
stimuli in their environment, and covers the processes commonly called "the senses": hearing, vision,
taste, smell and so on
Toxoplasmosis - parasitic infectious disease, which, if acquired during the first four months of pregnancy,
can cause serious fetal defects. Parasites are transmitted by certain animals or via raw meat
Trimester - any period of three months during pregnancy
Umbilical cord - the rope of three blood vessels which link the fetus to the placenta; all nutrients for and
waste products from the fetus pass through the umbilical cord
Uterus - womb, the best incubator in the world (the organ carrying and protecting the unborn baby)
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References
Emily Slone McKinney, S. R. (2017).Maternal-Child Nursing - E-Book. Canada: Elsevier Health Sciences.
M. Christine Neff, M. S. (2008).Introduction to Maternal and Child Health Nursing. Michigan: Lippincott
Williams & Wilkins.
Marcia L London, P. W.(2016).Maternal & Child Nursing Care. Canada: Pearson Education.
Mosby. (2009).Mosby's Medical Dictionary, 9th edition. Elsevier.
Pillitteri, A. (2006). Maternal and Child Health Nursing: Philippine. Chicago: Lippincott Williams & Wilkins.
Pillitteri, A. (2010). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family.
Chicago: Lippincott Williams & Wilkins.
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