LaFontaine with complete solution
Patient Status
Asked about patient's status.
Asked about patient's needs.
Asked about feelings towards pregnancy or delivery.
Patient Comfort
Asked about patient's symptoms.
Followed up on pain.
Asked about relieving factors.
Asked about current position.
Asked permission to conduct physical exam.
Intranatal histrory
Asked about contractions.
Asked how long she has been in labor.
Asked if water has broken.
Asked about pregnancy timeline.
Prenatal history
Asked about prenatal visits.
Followed up on delay in prenatal visits.
Asked about pregnancy conditions.
Past Medical History
Asked about preexisting conditions.
Asked about allergies.
Asked about hospitalizations.
Social History
Asked about support system.
Asked about substance abuse.
Asked about education.
Asked about living situation.
Assessed who will be primary caregiver.
Home Medications
Asked about home medications.
Review of Systems
Asked about review of gastrointestinal system.
Asked about review of urinary system.
Asked about review of cardiovascular system.
Education and Empathy
Water Breaking
Pain
Feeling Nervous
Nursing Diagnosis
readiness for effective parenting
Signs and Symptoms