Assessment # 1 – The Intrapartum Patient Assessment Patient Initials, Date, time & Hospital Patient’s Medical Diagnosis – This should include the Stage and Phase of Labor I. Important history information including prenatal & admission labs, onset of contractions, membrane status. II. Contraction: duration and frequency at the time of your assessment III. Cervical dilatation, effacement, & station of presenting part (time of exam) IV. Vital Signs, method of Pain management (pain scale) V. Fetal Monitoring: FHR Baseline, describe the type of Variability, presence of Accelerations, and decelerations. What kind of deceleration and nursing interventions? Is the tracing Category I, II or III? If the patient delivers on your shift: Date, time & type of delivery: Sex of infant: Apgar scores: Length of Stage III Perineal repair if any/ treatment Assessment of Fundus and lochia after delivery Bonding, BF & skin-to-skin achieved.
[Solved]: Assessment # 1 – The Intrapartum Patient Assessment…
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