Admission Information Suzanne Gordon DOB 09/27/1988
Health History
| Source of Information | Client | |||||||
| Reason for Visit | Caesarean | |||||||
| Health History | Gestational Diabetes | |||||||
| Height | 170 | cm | Weight | 150 | lbs | |||
| Allergies | Reaction type: | Severity: | ||||||
| Language Spoken | English | Reading/Writing | English | |||||
| Family History | ||||||||
| Previous Illnesses | Depression and Anxiety, Asthma | |||||||
| ARO Screening | Complete | MRSA: | Negative | CPO: | Negative | Close contact with someone positive: | No | |
| Isolation Precautions | Type: | |||||||
| Surgical History | ||||||||
| Wounds | ||||||||
| Aggressive Behavior Screening | History of Violence: | No | Physically violent: | No | Verbally Aggressive: | No | AGG FORM | No |
| Dietary History | Diabetic Diet | Diet Type: | Regular | Consistency: | Regular | |||
| Substance Use | Type: | NONE | Last Used: | |||||
| Substance Use | Type: | Last Used: | ||||||
| Housing | Home | Barriers: | Community Support: | Supportive family | ||||
Pre Admission Health Assessment
| HEENT (head, eyes, ears, nose, throat): no concerns |
| Integument: Denies rashes or wounds |
| Respiratory: Work of breathing easy. Chest clear. Equal air entry bilaterally. Denies cough. Denies smoking. RR 12 SpO2 97% room air. History of Asthma |
| Cardiovascular: Heart rate: 78 regular BP: 134/86 . Brisk cap refill all extremities. Denies cardiovascular health issues |
| Gastrointestinal: BSX4, denies nausea or vomiting |
| Genitourinary: Frequent urination currently, amber in color |
| Musculoskeletal: No concerns |
| Neurologic: Alert and oriented x 3. Denies headaches. |
| Endocrine: Gestational Diabetes |
| Lymphatic: denies lymphatic health issues |
| Pain: Acetaminophen for headaches and back aches, currently experiencing soreness to back, dull ongoing, 4/10, does not radiate. |
| Cognitive: Feels anxious in final weeks of pregnancy |
| Phycological: History of anxiety and depression |
| Assessment completed by: TG Litt RN Date: Pre C/S |
