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Anna Smith Medical HX: Objective date I don’t know how this fits with the Asthma problems (Data Gap) HR_68
RR_16_ _B/P: 110/75 Temp 98.2 Female, Reproductive HX: Age: 15 Menarche started at 14, reports periods
Wt_110_HT_5’4″_BMI_Today’s Does not drink/smoke are irregular. Does not recall LMP weight_12… Show more

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Presumptive Signs

Probable Signs

Positive signs

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SituationÂ should include Gravida/Para or GTPAL and Report of LMP, with estimation of EDC.

BackgroundÂ should include pertinent data from reproductive history, medical history, and family history as well as lifestyle information

AssessmentÂ should include objective and subjective data points that are important to the current situation. Signs of pregnancy will go here as well as your estimation of gestational age.

Recommendations: What follow-up, education is needed based on assessment and gestational age? What diagnostic tests should be run?Â

Should lifestyle changes be made? Should medications be changed?Â

Are vaccinations needed at this time?

Interdisciplinary: should referrals occur?Â

Should other healthcare services be engaged during this or subsequent visits?

R:Â

SCIENCE
HEALTH SCIENCE
NURSING
NUR 317

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