Question

SAMPLE DATA ON OB PHYSICAL ASSESSMENT

OB Physical Assessment Tool

Name of Client :                                                   Date of Assessment:

Age :

Address:

Chief Complaint(If any):____________________________________

I. Obstetrical History:

    a)   Menarche: ___________________

    b.) Last Menstrual Period (LMP: ________________

    c.) Expected Date of Confinement (EDC):_____________________   

           (based on Naegele’s Rule)

    d) Age of Gestation ( Based on LMP):_________________________

    e) Trimester of Pregnancy ( based on AOG)

          First Trimester    (0-13 weeks): ________ weeks

          Second Trimester (14-26 weeks):_______ weeks

          Third Trimester    (27-40 weeks):_________weeks

   f) Obstetrical Score

               Gravida:_______________    Para : ___________

                Term: ________                       Pre-Term :____________         

               Abortion:_______                    Living:__________

               Multiple Birth:________________

II. Physical Assessment:

     

          General Survey: _______________________________________

           ____________________________________________________

                            

           Mental Status:_________________________________________

           Anthropometric measurements :

                Height: ___________ (ft. and inches)        Weight:_______ kgs

                BMI:______________

           Vital signs:

                      Temperature:_______                Blood Pressure:_______

                      Pulse Rate:_________                 Respiratory Rate:______

            Breast :

                         Size:   Equal:_______               Unequal:__________

                         Shape: Symmetrical :______ Asymetrical:_______

                         Remarks:__________________________________

           

           Nipples:

                            Everted:________                 Inverted:________

                            Lump:__________

                            Discharges:   Present: _________       Absent: _______

          

          Abdomen :

                           Linea negra: _______         Striae gravidarum:____

                           Leopold’s Maneuver:

                                  Fundic Height:______________( hypothetical )

                                  Fetal Heart tone:___________ (hypothetical)      

Instruction: Assuming that you are to perform Leopold’s maneuver to , explain the following to your client in your own words:

                  a) What is Leopold’s maneuver

                  b) Describe how each maneuver will be performed

                  c) Possible findings of each maneuver

      First Maneuver:

           Findings: _____________________________________________

     Second Maneuver :

           Findings: ____________________________________________

   

     Third Maneuver :

          Findings: ____________________________________________

     Fourth Maneuver :

          Findings: ____________________________________________

    Perineum:

                   Scars:_______ Warts:_______ Rashes:________

                  Discharges :

                       Color :_________          Odor:__________

                       Appearance : Transparent (clear):_____

                                                 Turbid (unclear):______

III. Signs of Pregnancy

Direction: Interview your client, list down and categorize the signs of pregnancy presently experienced by your client.

Presumptive	Probable	Positive

Answer 1