ANGELES UNIVERSITY FOUNDATION

B Breast: Size, shape, & engorgement (usually occurs 2-3 days postpartum)
Angeles City -
COLLEGE OF NURSING

MOTHER
U Uterus: Is it contracted or not??
-
Name: Age: Sex: CS: Religion:

B Bladder: Is it painful urination? Color of urine? How many times?

-
Address: Birthday: Type of delivery:

B Bowel movement: Abdominal distension, flatus, presence of bowel movement,

CC / Diagnosis: Ward: Room #: Bed #: History of illness: hemorrhoids
Date and Time of Admission: -

L Lochia: Amount, color, odor, clots

VITAL -
SIGNS

Temperature: Temperature: E Episiotomy (gupit): Location, stitches, edema, redness, discharge

-

PR: PR:

S Skin: Color? Is it cold or warm?

RR: RR: -

8AM BP: 11AM BP:

H Homan’s Sign: (+) indicative of Deep Vein Thrombosis (dorse reflex)
-
O2 Sat: O2 Sat:

Pain: Pain: E Emotional status & maternal-child bonding (Breast feeding, holding her child)
(1 – 10): (1 – 10): Taking-in phase: Dependence, discomfort, and prefers to talk about labor
experiences. Taking hold phase: Starts to initiate actions and focuses on newborn.
Letting go: Finally accepts her new role
R Response: LOCALIZED PAIN 5

WITHDRAWALS FROM PAIN 4

FLEXES TO PAIN 3

EXTENDS TO PAIN 2
GPTPALM
G (# of pregnancy): Glasgow Coma Scale
P (24 weeks/500g): NO MOVEMENT 1
T (↑ 37 weeks):
P (25 – 36 weeks): EYE RESPONSE TOTAL
A (before viability – 24 weeks):
L (# living children):
M (multiple preg): SPONTANEOUSLY 4 Ask about: Hygiene:
Drinking Nails (Clean, Not Clean)
Smoking Teeth / mouth
OPEN TO VERBAL COMMAND 3 Hypertension / Hypotension Head
Anemic o Diabetic Nalinis na ba ang site:
Asthmatic o Heart Naligo na ba (Yes, No)
OPEN TO PAIN 2 Lungs o Liver
Breathing pattern
(fast, shallow)
NO EYE OPENING 1

VERBAL RESPONSE

ORIENTED 5

CONFUSED 4

INAPPROPRIATE WORDS 3
INTRAVENOUS FLUID + SIDE DRIP AND MEDICINES (given, instructed) DOSAGE
TPN FREQUENCY
INCOMPREHENSIBLE SOUNDS 2
IV Fluid
NO VERBAL REPONSE 1 Bottle No:

MOTOR RESPONSE Date & Time

Started:

FOLLOWS COMMAND 6
Type of IVF Which hand/arm? Amount:
& Volume

Drug BABY
Additives

Flow Rate Name: Age: Sex: Religion:

Infusion
Device

Which Address: Birthday:

hand/arm?

Ward: Room #: Bed #:

OTHER TREATMENT PROCEDURES DIET

VITAL
SIGNS

Temperature: Temperature:

8AM HR: 11AM HR:

Blood bottle No:
RR: RR:
Type of Blood:

Date and Time started:

Blood Component: Food to eat:

Avoid:
Amount:

Rate:

Time (IF consumed/closed): Attachment: