Post on 04-Jun-2018
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.