What This Document Is
This guide supports clinical assessment practice for students in the Nursing Care of the Childbearing Family (NURS 128) course at Imperial Valley College. It’s designed to be used *during* postpartum clinical rotations as a structured form for recording patient assessment findings. It is a required submission accompanying concept maps.
Why This Document Matters
This assessment guide is essential for nursing students completing their clinical hours focused on postpartum care. It ensures a systematic approach to evaluating a patient’s recovery after childbirth, covering vital signs, physical assessments, and psychological well-being. Successful completion and submission of this form are a clinical requirement. It’s used at the beginning of each clinical shift to establish a baseline and track changes in a patient’s condition.
Common Limitations or Challenges
This document is a *form* for recording data, not a learning tool for postpartum assessment itself. It provides headings and expected “normal” findings as a reference point, but does not teach *how* to perform assessments or interpret complex findings. Students will still need to rely on textbooks, lectures, and instructor guidance to fully understand postpartum physiology and potential complications.
What This Document Provides
This guide includes:
* Sections for documenting vital signs, pain assessment, and OB history.
* A structured format for assessing the breasts, abdomen/fundus, lochia, perineum, lower extremities, bladder, bowel elimination, and any incisions.
* Areas to record observations regarding psychological adaptation, attachment, rest/sleep, and infant feeding.
* Space to document perceptions of postpartum self-care and discharge plans.
* A section for recording relevant lab results and prenatal history.
This preview does *not* include the detailed “normal/textbook findings” for each assessment area beyond what is shown, nor does it include the complete concept map requirements. It also does not provide any instructional content on how to perform the assessments.