Clinical Care Guideline of N.S.D

Name _________________________

Anamnesis NO._________________________

Date of birth _______________

Blood Type _______

Drug allergy

NOTE

(NSD)

1

1. .. 2

2. .. 6

3. .. 8

4. . 9

5. . 10

6. . 11

12

Identifying data 1

Admission date

Discharge date

Anamnesis NO.

Bed NO.

Name

Sex

Date of birth

ID NO.

Address for receiving info.

Telephone number

Cell phone number

Emergency contact

Relationship

Telephone number

Cell phone number

Address for receiving info.

Weight kg

Height cm

Week

EDC

Drug allergy

Blood type

Diagnosis

Previous history

___________ ___________ ___________

Clinical Care Guideline Record of N.S.D. Pre-delivery

2

Admission Physical assessment

(Wt) Kg (Ht) cm

Basic physical data (TPR) BP mmHg

Consciousness

(alert) (drowsiness) (stupor) (obtunded) (confusion) (irritable) (others)

(pulse regular) (arrhythmia) (Pacemaker) (others)

Cardiovascular (chest pain) (respiratory tract) (smooth) (cough) (sputum) ( ) (respiratory tract) (others)

(rate and rhythm of breathing) (normal) (rapid) (slow) (deep) (not deep)(rate and style) (dyspnea) (others)

Respiratory

(breath sounds ) (normal) (wheeze) (stridor) (rhonchi) (breath sounds ) cracklessound (others)

(bowel sounds) (normal)5-34/min (rapid) (slow) (non) (abdomen) (bloating) (Soft) (hard) (tenderness) (Rebound tenderness) (mass) (others)

Gastrointestinal

tract (drain) (N-G tube)(___ _) (others) (____ ) (emiction) (normal) (micturition) dysuria (incontinence)(emiction) (on foley) (others)

Elimination

(bowel pattern) (normal) (constipation) (diarrhea) (incontinence) (bowel pattern) (colostomy )( ) (others)

(condition) (warm) (cold) (dry) (sweating) (color) (pale) (flush) (cyanosis) (jaundice) (pink)

(intact) (edema) ( __) (lesion)

Skin (appearance)

(trauma) (others) Activity

(normal) (weak) (bed rest) (handicapped)( ) (food)

(drug) Allergic history (others)

(smoking) (cessation) (drinking) (abstinence) (betel nut) (quit)

Addiction

(drugs)

/

(denture) ( ) (contact lens) (hearing aid)

Clinical Care Guideline Record of N.S.D. Pre-delivery

supplementary devices

(artificial eye) (artificial limbs) (walkers) (others)

____________________ 3

Clinical Care Guideline Record of N.S.D. Pre-delivery

5

(Pregnancy Physical assessment)

G P (SA) (AA) (ectopic pregnancy)

(week) (EDC)

Pregnancy history past history (PIH) (GDM) (Pre-eclampsia)

past history (Eclampsia)

(show) at am/pm

Signs of delivery (Hemorrhage) (total amount) ml at am/pm

Rupture of membranes

at am/pm(clear) (turbid)

Labor pain began

at am/pmInterval minDuration sec

Induced labor

(reason)

(method) at am/pm

Painless labor

start at am/pm(Dilation) cm (Drug)

Fetal position (Presentation) (Vertex) (Face) (Brow) (Breech)

Fetal head (Floating) (Partially engaged) (Engaged)

/

Fetus (F.H.R.) / (Estimated Weight)__________gm

Examination

bimanual palpation (monitor) (echography) (others)

(VDRL) (Neg) (Pos) (AIDS) (Neg) (Pos) HBs Ag (Neg) (Pos) HBe Ag (Neg) (Pos) (rubella) (Neg) (Pos)

CBCD/C(WBC) ul (Hgb)____g/dl. (platelet) / L

Blood tests

ABOblood group/Rh type( / Rh ) ( / Rh )

Urine test

(normal) (abnormal) (glycosuria) ( ) (proteinuria) ( )others

Physiological

(pain) others_________________________

Psychological (anxiety) others_________________________

Communication

(communication difficulty ) others_________________________

Others

_____________

Clinical Care Guideline Record of N.S.D. Pre-delivery

A. B. C. A B C

(special problem) (medical / nursing intervention)

Clinical Care Guideline Record of N.S.D. Pre-delivery

4

/

date/time

F.H.R.(/)

Uterus

contraction

()

Dilation(cm)

Effacement%

Station

TPR

(//)

BPmmHg

Drug / intervention

Signature

____ ____ ____ ___/___

____ ____ ____ ___/___

____ ____ ____ ___/___

____ ____ ____ ___/___

____ ____ ____ ___/___

____ ____ ____ ___/___

____ ____ ____ ___/___

____ ____ ____ ___/___

____ ____ ____ ___/___

____ ____ ____ ___/___

____ ____ ____ ___/___

____ ____ ____ ___/___

Clinical Care Guideline Record of N.S.D. Delivery

6

Rupture of Membranes

at am/pm

(artificial) (spontaneous)

(Vacuum Extraction)

Prenatal

preparedness (on foley) at am/pm ml (skin prepare)

(Vertex) .ROA .LOA .ROP .LOP .LOT

Fetal position

(Presentation) (Face) (Brow) (Breech) (Manual Rotation)

Anesthesia (Local infiltration) (Saddle block) (Painless labor)

(total amount) severe moderate profuse Amniotic fluid

(meconium stain)no light average abundant

Cervix intact lacerateddescription

Vagina abrasionlacerated

intact abrasion (Episiotomy.) Midline RML LML. Perineum laceration 1 2 3 4

at am/pm( spontaneous) (fundal pressure)

(Mechanism)(Schultz mechanism) (Duncan mechanism)

(appearance)(complete) ..(incomplete) lacerated

(appearance description)

Placenta

(Weight)gm

(total bleeding) ml ( gauze) Postpartum (uterus contraction)(hard) (soft)

(delivery)at am/pm (sex) ( male) (female)

(stillbirth) (living) (suction)

(appearance)

(meconium stain)

no light

averageabundant

(Umbilical cord)(Non) (Cord traction) (Loops)

Postnatal data

(Weight) gm (Height) cm (Head Circ) cm(Chest Circ) cm

skin to skinbeginat_______ am/pm endat_______ am/pm

/

suck on the table

Clinical Care Guideline Record of N.S.D. Delivery

7

Apgar

Score

(Score) 0 1 2 1 5

(Pulse)

(absent)

100/(slow and below 100)

100/ (over 100)

(Respiratory Effort)

(absent)

(Hypoventilation and weak crying)

(Good and strong crying)

(Activity)

(Flaccid)

(Some Flexion of Extremities)

(Active Motion)

(Grimace)

(No response)

(Lowering or some motion)

(Cough or sneeze)

(Appearance)

(Blue and Pale)

( Blue Extremities and pink body)

(Completely Pink)

(total)

(Oxytocin) Piton-s / a t am/pm Ergotrate/ a t am/pm 2% Xylocaine Local anesthesia / a t am/pm Methergin / a t am/pm (Plasma Expanders) B.T.() a t am/pmtotal _ml (Normal Saline) B.T.() a t __am/pmtotal ml

(special problem) (medical / nursing intervention)

__________________ __________________

Clinical Care Guideline Record of N.S.D.-- 1st. Day Postpartum

9

(uterus contraction)(hard) (soft) Uterus

recovery (Fundus)

(amout)(

Clinical Care Guideline Record of N.S.D.2nd. Day Postpartum

10

(uterus contraction)(hard) (soft) Uterus

recovery (Fundus)

(amout)(

(uterus contraction)(hard) (soft) Uterus

recovery (Fundus) (amout)(

Clinical Care Guideline Record of N.S.D.Postpartum 8

/ date/time

TPR (//)

BP

( mmHg)

Uterus contraction

()

Fundus

(__Fb)

lochia

()

emiction

Signature

____ ____ ____ ___/___

____ ____ ____ ___/___

____ ____ ____ ___/___

____ ____ ____ ___/___

____ ____ ____ ___/___

____ ____ ____ ___/___

____ ____ ____ ___/___

____ ____ ____ ___/___

____ ____ ____ ___/___

/

4

____ ____ ____ ___/___

_________________

12

()() ()()()

E. E1... E2.

A. A01.

A02. Hb10mg/dl

A03.Urine

A04. I. on fetal monitor

A04. .O2

A05. A06.

A07. P.P.H.

A08. P.I.H

A09. Spinal headache

A10. Hemorroid

A11. S.S.enema

A12.

F. F01..on Epidural

B01. .on PCA

B01. .

B01. .

F02..

F03. Urine100cc

F04.O2

F05.

F06. F07.

G. G01... G02.

B. B01..on Epidural

B01..on PCA

B01..

B01..

B02..

B03.

B04.

B05.

H. H01. BR.data H02. H03.

I.

C. B01..on Epidural

B01..on PCA

B01..

B01..

C02..

C03.

C04.

()() J01. J02.

J03.

12

D.

D01.

D02.

J04.

J05.