OCC School of Nursing Post-partum Data Assessment Tool/PCPOC
Name __Alexa Claeys________________________________________ Pt. Initials__EL_______Date of Care__9/16/25_____
OB Post partum: Demographics/General Information
Room #______5616________Initials: ___EL_____
Age: ___38________Admit date:__9/14/25________ Ht OB Post partum: Laboratory & Diagnostic Testing OB: Post-partum Medications
_5’10”_________ Wt _172 lb________
Complete with pre-clinical and update on clinical List all current medication orders.
Gravida/Para_G6P4_____ TPAL____T4P0A2L4_______
day.
Gestation___38 4/7 weeks_________
Indicate trends.
Length of Labor ____~27 hours________________
WBC_11.3_RBC_3.7_Hgb_10.8_Hct_32.1___ Ibuprofen 600mg q6h PRN
Date of Delivery _9/15/25_PP Day/POD#_PP Day 1____
Plts_123_ Blood type/RH _O+/RH_________
Time of Delivery____2058_______________________
PT/INR Acetaminophen 650mg PO q6h PRN
Allergies: latex, shellfish, sulfa___________________
PT_12.5 sec_PTT_32 sec_INR_1.0_
Medical History: Gilbert’s syndrome, anemia (iron transfusions x8),
CHEM (CMP/BMP) Oxycodone 5mg PO q4-6h PRN
hyperemesis gravidarum w/ PICC 5
BUN_14_Creat_0.9_ Na _138_ K_4.2_
months______________________________
Cl_101_Ca_9.2_Mg_1.8_PO4_3.5_
OB History/Risk Factor: polyhydramnios, LGA, GBS+, prior anemia, Ondansetron 4mg PO q6h PRN
Albumin_3.8_HgbA1C_~5.5_ Glucose (FBS/S) _90_
twin demise at 11
U/A_no signs of infection, no glucose_
weeks_______________________________________
Culture & Sensitivity (C&S)
Docusate sodium 100mg PO BID
Maternal Anesthesia: _epidural___________________
Site: _not performed/not indicated_
Postpartal risk factors: hemorrhage (polyhydramnios, LGA, anemia, Ferrous sulfate 32mg PO daily
Results: _not applicable_
multiparity), infection (GBS+), poor healing
Diagnostic Tests (XR, CT, U/S)
(anemia)______________________________ Prenatal vitamin PO daily
Test: not indicated_
Postpartum Phase: taking in →moving forward taking- Results: _not applicable_
hold_________________________________________
Maternal Diet: regular, tolerated poorly (nausea/vomiting)
_____________________________
VS: T 98.6 P 80 R 16 B/P 118/72 Pain 5/10
IV site: 20-gauge peripheral IV, LT forearm_________
OB Post partum: Respiration OB: Post partum: Circulation
OB Post partum: Neurosensory
Hx: _no significant respiratory history_ Hx: _anemia_
Hx: __none significant________________________ Objective Data Objective Data
Objective Data Resp. rate _16_ Pulse oximetry _98%_ BP _118_/_72_ Apical Pulse: _80_
LOC conscious PERRLA_ pupils are equal, round, and reactive to O₂ vs Room Air _room air_ O₂ Type _none_ Reg./Irreg._regular_
light bilaterally Resp: unlabored, labored, use of accessory
Oriented to person/place/time/situation X4 Peripheral pulses _palpable/present bilaterally_
muscles? _unlabored_ Cap refill _<2 sec_
Affect/Mood _pleasant_______________________ Lung Sounds:
Behavior _appropriate________________________ Edema _not present_
Anterior_ clear bilaterally_
Sensory impairment? __none______________________ Posterior: _ clear bilaterally_
Other _none_
Motor impairment? _none noted. Patient ambulates without Subjective Data reports mild fatigue
Cough_not present_ Sputum _not present_
difficulty, strength equal b/l_____________ Other _none_
Subjective Data _reports no dizziness or visual disturbances___ Subjective Data denies SOB
, OCC School of Nursing Post-partum Data Assessment Tool/PCPOC
Name __Alexa Claeys________________________________________ Pt. Initials__EL_______Date of Care__9/16/25_____
OB Post partum: Elimination
Hx: kidney stones, UTI. Kidney disease, dialysis, peptic ulcer disease, hepatitis, cirrhosis,
OB Postpartum: Activity/Rest
intestinal/gastric surgeries, GERD, Crohn’s, Colitis other: _hyperemesis gravidarum_
Other: _mild fatigue reported, otherwise no significant limitations_
Objective Data
Objective Data
Foley catheter? _yes_ Date of insertion? _9/15/25_ Date of Removal_9/15/25_ ROM: _full range of motion in all extremities_
Voiding/ Amount _voiding spontaneously, ~300mL per void_ Time of last void _9/16 at 1400_ Muscle tone/strength/symmetry _normal tone and strength, equal bilaterally_
Urine color_yellow,clear_ I/O _balanced, intake 2200mL IV fluids during labor, urine output Gait _steady, independent ambulation without assistance_
~2000mL_ Physical therapy/Occupational therapy order _none_
Previous 24 hour I/O_+200mL_ Activity order _ambulate as tolerated, advance activity gradually_
Abdomen: Distension _nondistended_ Firm/soft _soft_ Fall Risk _high_ Reason _postpartum status, recent delivery, fatigue, potential
Bowel Sounds/location: _normoactive in RUQ, RLQ, LUQ, LLQ_ orthostatic changes_ Assistive/Adaptive Devices _none required_
Date of last BM: _9/14/25_BM pattern: _regular_ Safety Issues _standard postpartum fall precautions reinforced (rise slowly, call for
Other: _passing flatus; mild postpartum constipation risk due to anesthesia/iron assistance if feeling weak, side rails up, non-skid socks in place) _
supplementation_ Subjective Data _patient states she feels “tired but okay” and is able to ambulate
Subjective Data _patient reports mild hesitancy with first void but no dysuria. Endorsed feeling independently. Denies dizziness, weakness, or imbalance when walking. Reports
“a little bloated” but denies severe abdominal pain. States she has not yet had a bowel mild muscle soreness from labor but improving with rest.
movement since delivery but expects by tomorrow. No complaints of burning, urgency, or
hematuria._
OB: Post partum: Safety
OB: Post partum: Pain/Discomfort OB: Post partum; Hygiene Hx: CA, anemia, immunosuppression, Falls, wds, other:
Hx: _no chronic pain history. Reports typical labor/postpartum Hx: _no history of skin disorders, poor Isolation: _none_
pain_ Vaccines: Flu _considering_ Pneumovax: _not indicated_
hygiene_
Objective COVID _vaccinated_ MMR _immune_
Location: _perineum and lower abdomen (uterine cramping) Objective Assess: bruise, color, jaundice, petechiae, and fatigue
Assessment: _mild to moderate discomfort, improving with Self-Care no abnormal bruising, skin color pink, no jaundice, petechiae. Reports
interventions. No abnormal swelling/hematoma observed. _ Dressing: _independent_ mild fatigue.
Subjective Data Fall Risk Score/Scale: _10/Obstetric Fall Risk Assessment Tool_
Location: _perineal_
Independent/Dependent/Assistance
Temp/route: _98.6 oral_
Intensity: _mild/moderate_ Bathing: _independent, instructed on General Appearance: _well groomed, no apparent distress_
Pain Scale: _5/10 at worst, 2-3/10 after interventions_ perineal care and importance of sitz Eyes _clear, no icterus_ Mucous membranes _moist, pink_
Quality: _described as aching and menstrual cramps_ baths/cleansing_ Color _appropriate for ethnicity, no pallor_
Duration: _intermittent, worse with breastfeeding_ Turgor _instant recoil_
Relief Measures: Independent/Dependent/Assistance
Braden scale: _20_ Edema_trace edema b/l_
Non-Pharmacological: Toileting: _independent, using peri Moisture/texture _skin warm, dry, intact_
_ice packs to perineum, rest, repositioning, peri-care_ bottle effectively after voids_ Integrity: wounds/incisions _2nd degree perineal laceration with sutures,
Pharmacological: _ibuprofen 600mg q6h PRN, acetaminophen well approximated, mild swelling, no erythema, drainage, or hematoma
Independent/Dependent/Assistance
650mg PR q6h PRN_ noted._
Patient Goal: _to maintain pain at 3/10 or less to allow for Subjective Data _patient states she feels
Dressings: _peri pad in place, clean, dry, no surgical dressings_
ambulation_ comfortable managing hygiene/peri care_
Subjective Data _none_
Name __Alexa Claeys________________________________________ Pt. Initials__EL_______Date of Care__9/16/25_____
OB Post partum: Demographics/General Information
Room #______5616________Initials: ___EL_____
Age: ___38________Admit date:__9/14/25________ Ht OB Post partum: Laboratory & Diagnostic Testing OB: Post-partum Medications
_5’10”_________ Wt _172 lb________
Complete with pre-clinical and update on clinical List all current medication orders.
Gravida/Para_G6P4_____ TPAL____T4P0A2L4_______
day.
Gestation___38 4/7 weeks_________
Indicate trends.
Length of Labor ____~27 hours________________
WBC_11.3_RBC_3.7_Hgb_10.8_Hct_32.1___ Ibuprofen 600mg q6h PRN
Date of Delivery _9/15/25_PP Day/POD#_PP Day 1____
Plts_123_ Blood type/RH _O+/RH_________
Time of Delivery____2058_______________________
PT/INR Acetaminophen 650mg PO q6h PRN
Allergies: latex, shellfish, sulfa___________________
PT_12.5 sec_PTT_32 sec_INR_1.0_
Medical History: Gilbert’s syndrome, anemia (iron transfusions x8),
CHEM (CMP/BMP) Oxycodone 5mg PO q4-6h PRN
hyperemesis gravidarum w/ PICC 5
BUN_14_Creat_0.9_ Na _138_ K_4.2_
months______________________________
Cl_101_Ca_9.2_Mg_1.8_PO4_3.5_
OB History/Risk Factor: polyhydramnios, LGA, GBS+, prior anemia, Ondansetron 4mg PO q6h PRN
Albumin_3.8_HgbA1C_~5.5_ Glucose (FBS/S) _90_
twin demise at 11
U/A_no signs of infection, no glucose_
weeks_______________________________________
Culture & Sensitivity (C&S)
Docusate sodium 100mg PO BID
Maternal Anesthesia: _epidural___________________
Site: _not performed/not indicated_
Postpartal risk factors: hemorrhage (polyhydramnios, LGA, anemia, Ferrous sulfate 32mg PO daily
Results: _not applicable_
multiparity), infection (GBS+), poor healing
Diagnostic Tests (XR, CT, U/S)
(anemia)______________________________ Prenatal vitamin PO daily
Test: not indicated_
Postpartum Phase: taking in →moving forward taking- Results: _not applicable_
hold_________________________________________
Maternal Diet: regular, tolerated poorly (nausea/vomiting)
_____________________________
VS: T 98.6 P 80 R 16 B/P 118/72 Pain 5/10
IV site: 20-gauge peripheral IV, LT forearm_________
OB Post partum: Respiration OB: Post partum: Circulation
OB Post partum: Neurosensory
Hx: _no significant respiratory history_ Hx: _anemia_
Hx: __none significant________________________ Objective Data Objective Data
Objective Data Resp. rate _16_ Pulse oximetry _98%_ BP _118_/_72_ Apical Pulse: _80_
LOC conscious PERRLA_ pupils are equal, round, and reactive to O₂ vs Room Air _room air_ O₂ Type _none_ Reg./Irreg._regular_
light bilaterally Resp: unlabored, labored, use of accessory
Oriented to person/place/time/situation X4 Peripheral pulses _palpable/present bilaterally_
muscles? _unlabored_ Cap refill _<2 sec_
Affect/Mood _pleasant_______________________ Lung Sounds:
Behavior _appropriate________________________ Edema _not present_
Anterior_ clear bilaterally_
Sensory impairment? __none______________________ Posterior: _ clear bilaterally_
Other _none_
Motor impairment? _none noted. Patient ambulates without Subjective Data reports mild fatigue
Cough_not present_ Sputum _not present_
difficulty, strength equal b/l_____________ Other _none_
Subjective Data _reports no dizziness or visual disturbances___ Subjective Data denies SOB
, OCC School of Nursing Post-partum Data Assessment Tool/PCPOC
Name __Alexa Claeys________________________________________ Pt. Initials__EL_______Date of Care__9/16/25_____
OB Post partum: Elimination
Hx: kidney stones, UTI. Kidney disease, dialysis, peptic ulcer disease, hepatitis, cirrhosis,
OB Postpartum: Activity/Rest
intestinal/gastric surgeries, GERD, Crohn’s, Colitis other: _hyperemesis gravidarum_
Other: _mild fatigue reported, otherwise no significant limitations_
Objective Data
Objective Data
Foley catheter? _yes_ Date of insertion? _9/15/25_ Date of Removal_9/15/25_ ROM: _full range of motion in all extremities_
Voiding/ Amount _voiding spontaneously, ~300mL per void_ Time of last void _9/16 at 1400_ Muscle tone/strength/symmetry _normal tone and strength, equal bilaterally_
Urine color_yellow,clear_ I/O _balanced, intake 2200mL IV fluids during labor, urine output Gait _steady, independent ambulation without assistance_
~2000mL_ Physical therapy/Occupational therapy order _none_
Previous 24 hour I/O_+200mL_ Activity order _ambulate as tolerated, advance activity gradually_
Abdomen: Distension _nondistended_ Firm/soft _soft_ Fall Risk _high_ Reason _postpartum status, recent delivery, fatigue, potential
Bowel Sounds/location: _normoactive in RUQ, RLQ, LUQ, LLQ_ orthostatic changes_ Assistive/Adaptive Devices _none required_
Date of last BM: _9/14/25_BM pattern: _regular_ Safety Issues _standard postpartum fall precautions reinforced (rise slowly, call for
Other: _passing flatus; mild postpartum constipation risk due to anesthesia/iron assistance if feeling weak, side rails up, non-skid socks in place) _
supplementation_ Subjective Data _patient states she feels “tired but okay” and is able to ambulate
Subjective Data _patient reports mild hesitancy with first void but no dysuria. Endorsed feeling independently. Denies dizziness, weakness, or imbalance when walking. Reports
“a little bloated” but denies severe abdominal pain. States she has not yet had a bowel mild muscle soreness from labor but improving with rest.
movement since delivery but expects by tomorrow. No complaints of burning, urgency, or
hematuria._
OB: Post partum: Safety
OB: Post partum: Pain/Discomfort OB: Post partum; Hygiene Hx: CA, anemia, immunosuppression, Falls, wds, other:
Hx: _no chronic pain history. Reports typical labor/postpartum Hx: _no history of skin disorders, poor Isolation: _none_
pain_ Vaccines: Flu _considering_ Pneumovax: _not indicated_
hygiene_
Objective COVID _vaccinated_ MMR _immune_
Location: _perineum and lower abdomen (uterine cramping) Objective Assess: bruise, color, jaundice, petechiae, and fatigue
Assessment: _mild to moderate discomfort, improving with Self-Care no abnormal bruising, skin color pink, no jaundice, petechiae. Reports
interventions. No abnormal swelling/hematoma observed. _ Dressing: _independent_ mild fatigue.
Subjective Data Fall Risk Score/Scale: _10/Obstetric Fall Risk Assessment Tool_
Location: _perineal_
Independent/Dependent/Assistance
Temp/route: _98.6 oral_
Intensity: _mild/moderate_ Bathing: _independent, instructed on General Appearance: _well groomed, no apparent distress_
Pain Scale: _5/10 at worst, 2-3/10 after interventions_ perineal care and importance of sitz Eyes _clear, no icterus_ Mucous membranes _moist, pink_
Quality: _described as aching and menstrual cramps_ baths/cleansing_ Color _appropriate for ethnicity, no pallor_
Duration: _intermittent, worse with breastfeeding_ Turgor _instant recoil_
Relief Measures: Independent/Dependent/Assistance
Braden scale: _20_ Edema_trace edema b/l_
Non-Pharmacological: Toileting: _independent, using peri Moisture/texture _skin warm, dry, intact_
_ice packs to perineum, rest, repositioning, peri-care_ bottle effectively after voids_ Integrity: wounds/incisions _2nd degree perineal laceration with sutures,
Pharmacological: _ibuprofen 600mg q6h PRN, acetaminophen well approximated, mild swelling, no erythema, drainage, or hematoma
Independent/Dependent/Assistance
650mg PR q6h PRN_ noted._
Patient Goal: _to maintain pain at 3/10 or less to allow for Subjective Data _patient states she feels
Dressings: _peri pad in place, clean, dry, no surgical dressings_
ambulation_ comfortable managing hygiene/peri care_
Subjective Data _none_
