GENERAL OBJECTIVE AND SPECIFIC OBJECTIVES (GOSO)

HRN : ___________________________________ Date: _______________

Hospital: __________________________________ Shift: _______________
Clinical Instructor: ___________________________ Area: _______________
GENERAL OBJECTIVE

1ST DAY 2ND DAY

SPECIFIC OBJECTIVES

1ST DAY 2ND DAY

Knowledge

1. 1.

2. 2.

Skills

1. 1.

2. 2.

Attitude

1. 1.

2. 2.

CLINICAL TEACHING PLAN

Time Activities

1ST Day 2ND Day

 MATERNAL HEALTH ASSESSMENT

Instructions: Kindly fill-out the forms with the necessary information of the
patient. Write legibly and accurately.

I. PATIENT’S PROFILE

HRN : Age: Birth Date : Sex: Civil Status : Religion: Address : Height:
Educational Attainment : Weight: Occupation : Blood Type Ethnic Group :
Vital Signs
Date & Time of Admission: BP: Attending Physician : RR: Medical
Diagnosis : PR: Temp:
History of Allergy/ies :

Delivery Details :

Type of Delivery :
Medications (if given)

Date of Delivery : Time:

Estimated blood loss:
Episiotomy Type :
Degree of Laceration: Type of Placenta:

II. OBSTETRIC HISTORY

LMP: G: P: _ (T: , P: , A: , L: ) EDC: _
AOG:
Age of Menarche: __ Menstrual Cycle: days Duration :
Gravida Place of Delivery AOG Manner Presentation Complications
 of
Delivery

G1

G2

G3

G4

G5

G6

G7

III. OBSTETRIC RISK FACTORS

[ ] Age (below 18 and above 35) [ ] Multiple Pregnancy [ ]
Ovarian Cyst [ ] Uterine Myoma [ ] Placenta previa
[ ] History of still birth [ ] History of 3 Miscarriages [ ] History of pre-
eclampsia/eclampsia [ ] Others: (please specify) _ _
IV. ANTENATAL HISTORY
Variables 1ST TRIMESTER 2ND TRIMESTER 3RD TRIMESTER

Number of
Visits

Signs &
Symptoms
of
Pregnancy

Diagnostic/s
&
Laboratory
Test/s Result

Immunization
/s Given

Medication
/s Taken
 V. FAMILY HEALTH HISTORY
[ ] Diabetes [ ] Asthma [ ] HPN [ ] Allergy [ ] Bleeding disorder[ ] Mental
Disorder [ ] Heart disease [ ] Epilepsy [ ] Others:

VI. PAST HEALTH HISTORY

Medical History: Hospitalized? [ ] Yes [ ] No
If Yes, when? __
Reason of hospitalization:
_
_
_
_
_

Surgical History: [ ] Yes [ ] No

If Yes, when?
Reason and type of Surgery
_
_
_
_
_
VII. FAMILY PLANNING METHOD HISTORY
A. Natural Method
[ ] Calendar Method [ ] Abstinence [ ] Withdrawal
[ ] Cervical Mucus [ ] Basal Body Temperature
[ ] Standard Days Method [ ] Lactational Amenorrhea Method
[ ] Others: _

B. Artificial Method
[ ] IUD [ ] Pills [ ] Injectable (DEPO) [ ] Condom [ ] Bilateral Tubal
Ligation (BTL) [ ] Intradermal Implant
[ ] Others:
REVIEW OF SYSTEMS

Instructions: Kindly accomplish this matrix. Be sure to fill out with normal and
abnormal findings. Follow the IPPA or IAPP (Inspection, Percussion, Palpation
and Auscultation) format. (Only for systems that are applicable)
BODY 1ST DAY 2ND DAY
PART/SYSTEM

General
Survey/
Mental Status
Integumentary

Head & Face

Neck

Eyes

BODY 1ST DAY 2ND DAY

PART/SYSTEM

Ears
Nose & Sinuses

Mouth & Throat

Lungs & Thorax

Breast & Axillae

Heart

BODY 1ST DAY 2ND DAY

PART/SYSTEM
 Abdomen

Gastrointestin
al/ Nutrition

Musculoskeletal

Genitourinary

Neurologic

BUBBLE-HEE ASSESSMENT
Instruction: Please write your focused assessment on the specific areas for
obstetric and gynecologic assessment. Be sure to categorize your findings into
IPPA (Inspection, Palpation, Percussion and Auscultation) format.
Assessment Area 1st Day 2nd Day

BREASTS
feeding method (if
breast feeding,
state frequency,
duration), bra,
appearance,
palpation, nipples

UTERUS
fundus, diastasis
recti (vaginal birth
only), tenderness,
C/S
dressing/ incision,
binder

BLADDER
Bladder distension,
voiding adequately,
or Foley output,
S/Sx of infection

BOWEL
Bowel sounds,
passing flatus (C/S),
BM
Assessment Area 1st Day 2nd Day

LOCHIA
Amount, color,
odor, clots

EXTREMITY
Edema, pedal
pulses,
capillary refill,
signs &
symptoms of
DVT (redness,
pain,
increased skin
temperature,
unilateral swelling)

HOMAN’S SIGN
Degree of pain,
calf
circumference,
color, capillary refill

EPISIOTOMY
Degree of
laceration,
perineum
(REEDA –
Redness, Edema,
Ecchymosis,
Drainage,
Approximation),
comfort measures,
Kegels;
HEMORRHOIDS –
pain, comfort
measures
 Assessment Area 1st Day 2nd Day

EMOTIONAL
LABILITY

MONITORING SHEET

Instructions: Fill – out the necessary data on vital signs monitoring and
intake and output sheet accordingly.

A. Vital Signs Monitoring

Shift: _
Date & Temp HR/PR RR BP O2 Sat
Time
 B. Intake & Output Monitoring
Shift: _
Date & Intake Output
Time

IVF IVTT PO Others Total Urine Stool Others Total

TOTAL INTAKE TOTAL OUTPUT

Pharmacotherapy & Nursing Responsibilities

Drug Mechanism Indications or Contraindications Side Effects
of Action Purpose
Generic Name:

Brand Name:

Classification:
 Dose, Route &
Timing:

MEDICAL MANAGEMENT & NURSING RESPONSIBILITIES

Instructions: Fill – out the necessary information required on the tables.

I. Intravenous Fluid Therapy and Nursing Responsibilities
Intravenous Fluids General Description Indication or Purpose

NURSING PROCESS RECORD

Patient’s Name :
__________________________________________________________________________
__________________________ Medical Diagnosis :
__________________________________________________________________________
__________________________
NANDA Nursing Diagnosis:

NANDA Definition:
 CUES/Defining NURSING NURSING RATIONA
Characteristics OUTCOMES INTERVENTIONS
CLASSIFICATION CLASSIFICATION (NIC)
(NOC)

Reference/s:
__________________________________________________________________________
_________________________________