What does your assessment look like?

  1. I'm a new grad in L&D, I'm curious to know what your assessments look like on your laboring patients. I know it might vary based on several factors but for a regular patient let's say you come on shift (or get an admit) what are the things you always look at/ask? Curious to know because I've shadowed people who ask about pregnancy complications, headaches, numbness or tingling, and listen to heart/lungs/belly and I've shadowed people who just ask about pregnancy complications.

    As I get ready to make my own process, I'd like to know what your assessments look like.
  2. Visit AZBlueBell profile page

    About AZBlueBell, ADN, RN

    Joined: Feb '15; Posts: 388; Likes: 387
    Specialty: 1 year(s) of experience in L&D


  3. by   klone
    I will assess lungs, abdominal tenderness/rigidity (both during and between contractions), DTRs, pedal edema, clonus, output. I will ask about headache, vision changes, epigastric pain, vaginal bleeding, fluid leakage.
  4. by   ashleyisawesome
    When I admit a new patient or get them for the first time, I usually listen to heart/lungs/bowel sounds. Check for edema, feel pedal pulses, check for clonus, do a homans test, ask about pain, ask if they are having head ache/blurred vision, assess their amniotic fluid color/smell if they are ruptured, palpate contractions for intensity, and check all lines (including epidural if they have one) to make sure they are connected and running the right stuff. Then throughout my shift I do a more focused assessment every couple of hours. I only check DTRs if they are pre-eclamptic or on Mag.