WEEK 1

Item Points
GOSO
Clinical Teaching Plan
Morse Fall Scale (Fall Assessment)
Maternal Health Assessment
Review of Systems
Bubble-Hee Assessment
Diagnostic, Laboratory Procedures and its Nursing
Responsibilities
Medical Management and its Nursing Responsibilities
i. Intravenous Fluid Therapy & NR
ii. Pharmacotherapy & NR
Vital Signs Monitoring
TPR Sheet
Nursing Process Record
Breastfeeding Observation Aid
Evidence – Based Nursing Research (Reflection Paper)
Total

___________________Lharra Mae C. Postrano, RN__________________

Clinical Instructor

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 GENERAL OBJECTIVE AND SPECIFIC OBJECTIVES (GOSO)

HRN : _143________________________________ Date: March 26, 2020___

Hospital: Bukidnon Provincial Hospital Kibawe Shift: 6:00 AM- 2:00 PM_
Clinical Instructor: Lharra Mae C. Postrano Area: Obstetric Ward___

GENERAL OBJECTIVE
1ST DAY 2ND DAY
At the end of 8 hours I will be able to At the end of 8 hours I will be able to
perform the basic assessing skills continue my assessing skills in
and procedure with ease and gathering the remaining data needed
competence and manifest positive and always show a desirable attitude
and desirable attitude needed in the towards my patient, hospital staff,
promotion of optimal health and my clinical instructor as well to my
prevention of illnesses to those fellow student nurses.
committed to my care.

SPECIFIC OBJECTIVES
1ST DAY 2ND DAY
Knowledge
1. At the end of 8 hours I will be 1. At the end of 8 hours I will be able
able to gather data appropriately to gather the remaining data
and completely and validates it. needed.

2. To analyze and interpret 2. To give health teaching to the

collected data, to apply what I patient.
have learned for the past
semesters
Skills
1. To respond and give the care the 1. To always be ready and at the
patients needed side of the patient in case it needs
anything.
To properly perform procedure such [Link] properly deliver the health
as doing physical assessments and teachings effectively to the patient
giving medication as ordered.
Attitude
1. To be polite and respectful to self 1. To be courteous to every people
and others. met along the way

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2. To be aware and understand the 2. To be able to give tender love and
needs and emotions of others. care to the patient.

CLINICAL TEACHING PLAN

Activities
Time 1ST Day 2ND Day

MORSE FALL SCALE

(Fall Assessment)

HRN: 143 Age: 26 years old Date: March

26, 2020
Instruction: Write the score that corresponds to the item being assessed on the
space provided.
Item Item Score Patient Score
1. History of falling (immediate or previous) No 0
Yes 25 __0____
2. Secondary diagnosis (≥ 2 medical No 0

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 diagnosis in chart Yes 15 ___0___
3. Ambulatory aid
⮚ None/bedrest/nurse assist 0
⮚ Crutches/cane/walker 15
⮚ furniture 30 ___0___
4. Intravenous therapy/heparin lock No 0
__0____
Yes 20
5. Gait
⮚ Normal/bedrest/wheelchair 0
⮚ Weak* 10
⮚ Impaired* 20 ___10___
6. Mental status
⮚ Oriented to own ability 0
⮚ Overestimates/forgets limitations 15 ___0___
TOTAL: 10
Interpretation: Tally the patient score and record.
<25 : Low risk
25-45 : Moderate risk
>45 : High risk

Note:
⮚ Weak Gait: Short steps (may shuffle), stooped but able to lift head while walking, may
seek support from furniture while walking, but with light touch (for reassurance).
⮚ Impaired gait: Short steps with shuffle; may have difficulty arising from chair; head down;
significantly impaired balance, requiring furniture, support person, or walking aid to walk.
⮚ Suggested scoring based on Morse JM, Black C, Oberle K, et al. A prospective study to
identify the fall-prone patient. Soc Sci Med 1989; 28(1):81-6. However, note that Morse
herself said that the appropriate cut-points to distinguish risk should be determined by
each institution based on the risk profile of its patients. For details, see Morse JM, Morse
RM, Tylko SJ. Development of a scale to identify the fall-prone patient. Can J
Aging 1989;8;366-7.

MATERNAL HEALTH ASSESSMENT

Instructions: Kindly fill-out the forms with the necessary information of the
patient. Write legibly and accurately.

I. PATIENT’S PROFILE

HRN : 143 Age: 26 yrs

Birth Date : February 14, 1994 Sex: Femal
e
Civil Status : Single Religion: Roma
n
Catho

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 lic
Address : Height: 155
cm
Educational Attainment : High school graduate Weight: 55 kg
Occupation : Housewife Blood Type A+
Ethnic Group : Talaandig Vital Signs
Date & Time of Admission: March 15, 2020; 8:05 am BP: 95/50
Attending Physician : Dr. Postrano RR:
Medical Diagnosis : Ruptured Ectopic Pregnancy PR: 120
bpm
Temp: 35.9C
History of Allergy/ies : N/A

Delivery Details :

Type of Delivery :
Medications (if given)

Date of Delivery : Time:

Episiotomy Type : Estimated blood loss:

Degree of Laceration: Type of Placenta:

II. OBSTETRIC HISTORY

LMP: February 7, 2020 G: _1__ P: ___ (T: ___, P: _1__, A: ___, L: ___)
EDC: November 14, 2020
AOG: _______________
Age of Menarche: 12 years old Menstrual Cycle: 27 days
Duration : 3-5 Days

Gravid Place of Delivery Manner of Presentatio Complication

a Delivery n s
AOG

G1 N/A N/A N/A N/A N/A

G2
G3
G4
G5
G6
G7

III. OBSTETRIC RISK FACTORS

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 [ ] Age (below 18 and above 35) [ ] Multiple Pregnancy

[ ] Ovarian Cyst [ ] Uterine Myoma [ ] Placenta previa

[ ] History of still birth [ ] History of 3 Miscarriages
[ ] History of pre-eclampsia/eclampsia [ ] Others: (specify)
Ectopic Pregnacy
IV. ANTENATAL HISTORY

Variables 1ST TRIMESTER 2ND TRIMESTER 3RD TRIMESTER

N/A N/A N/A
Number of
Visits

N/A N/A N/A

Signs &
Symptoms of
Pregnancy
N/A N/A N/A

Diagnostic/s &
Laboratory
Test/s Result

N/A N/A N/A

Immunization/
s Given

N/A N/A N/A

Medication/s
Taken

V. FAMILY HEALTH HISTORY

[ /] Diabetes [ ] Asthma [ /] HPN [ ] Allergy
[ ] Bleeding disorder [ ] Mental Disorder [ ] Heart disease [ ] Epilepsy

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 [ ] Others: __________________________________________________

VI. PAST HEALTH HISTORY

Medical History: Hospitalized? [/ ] Yes [ ] No
If Yes, when? When she was 19 years
old
Reason of hospitalization: because of
clamydia_________________________________________
________________________________________________
________________________________________________
_______________

Surgical History: [ ] Yes [/ ] No

If Yes, when? ___________________
Reason and type of Surgery
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
VII. FAMILY PLANNING METHOD HISTORY
A. Natural Method
[ ] Calendar Method [ ] Abstinence [ ] Withdrawal
[ ] Cervical Mucus [ ] Basal Body Temperature
[ ] Standard Days Method [ ] Lactational Amenorrhea Method
[ ] Others:
_N/A____________________________________________

B. Artificial Method
[ ] IUD [ ] Pills [ ] Injectable (DEPO) [ ] Condom
[ ] Bilateral Tubal Ligation (BTL) [ ] Intradermal Implant
[ ] Others:
_N/A____________________________________________

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 REVIEW OF SYSTEMS

Instructions: Kindly accomplish this matrix. Be sure to fill out with normal and
abnormal findings. Follow the IPPA or IAPP (Inspection, Percussion, Palpation
and Auscultation) format. (Only for systems that are applicable)
BODY 1ST DAY 2ND DAY
PART/SYSTEM
Received patient lying flat Received patient lying flat
and still on bed, pale and and still on bed, pale and
looks unwell, drowsy. looks unwell, drowsy.

General Survey/
Mental Status

Evenly colored skin tones Evenly colored skin tones

without unusual or without unusual or
prominent discolorations, prominent discolorations,
no odor of perspiration no odor of perspiration
during inspection of the during inspection of the
skin. Skin is intact and no skin. Skin is intact and no
reddened areas. Smooth, reddened areas. Smooth,
without lesions. Presence without lesions. Presence
Integumentary of striae marks can be of striae marks can be
seen in the abdominal seen in the abdominal
area. Peripherally hands area. Peripherally hands
are cold and clammy. Skin are cold and clammy. Skin
is mobile, with elasticity is mobile, with elasticity

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 and returns to original and returns to original
shape quickly. Natural hair shape quickly. Natural hair
color, evenly distributed, color, evenly distributed,
scalp is clean and dry, hair scalp is clean and dry, hair
is smooth and firm, elastic. is smooth and firm, elastic.
Nails are clean, newly Nails are clean, newly
trimmed, pale tones is trimmed, pale tones is
visible, hard, and immobile. visible, hard, and immobile.
Nail plate is attached firmly Nail plate is attached firmly
to the nail bed. Slow to the nail bed. Slow
capillary nail bed refill. capillary nail bed refill.
Head is symmetric, round, Head is symmetric, round,
erect, and in midline, erect, and in midline,
appropriately related to appropriately related to
body size. Head is hard body size. Head is hard
and smooth, without and smooth, without
lesions. Face is symmetric, lesions. Face is symmetric,
with round appearance. No with round appearance. No
abnormal movements abnormal movements
Head & Face noted. Temporal artery is noted. Temporal artery is
elastic and not tender. No elastic and not tender. No
swelling, tenderness, or swelling, tenderness, or
crepitation with movement, crepitation with movement,
mouth opens and closes mouth opens and closes
fully (3-6cm between upper fully (3-6cm between upper
and lower teeth). Lower jaw and lower teeth). Lower jaw
moves laterally 1-2cm in moves laterally 1-2cm in
each direction. each direction.
Neck is symmetric, with Neck is symmetric, with
head centered and without head centered and without
bulging masses. Thyroid bulging masses. Thyroid
cartilage and cricoid cartilage and cricoid
cartilage move upward cartilage move upward
symmetrically as the client symmetrically as the client
swallows. Trachea is swallows. Trachea is
Neck midline, thyroid gland is not midline, thyroid gland is not
palpable. palpable.
No bruits are auscultated, No bruits are auscultated,
no swelling or enlargement no swelling or enlargement
and no tenderness present and no tenderness present
on preauricular and on preauricular and
tonsillar nodes. tonsillar nodes.

Eye movement is smooth Eye movement is smooth

and symmetric throughout and symmetric throughout
all six directions. Skin on all six directions. Skin on
both eyelids is without both eyelids is without
redness, swelling, or redness, swelling, or
lesions. Eyeballs are lesions. Eyeballs are
symmetrically aligned in symmetrically aligned in

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 Eyes sockets without protruding sockets without protruding
or sinking. Bulbar or sinking. Bulbar
conjunctiva is clear, moist, conjunctiva is clear, moist,
and smooth. Sclera is and smooth. Sclera is
white. Palpebral white. Palpebral
conjunctiva is free of conjunctiva is free of
swelling, foreign bodies or swelling, foreign bodies or
trauma. No drainage noted trauma. No drainage noted
from the puncta during from the puncta during
palpation. Cornea is palpation. Cornea is
transparent, with no transparent, with no
opacities. Iris is typically opacities. Iris is typically
round, flat, and evenly round, flat, and evenly
colored. Pupil is round with colored. Pupil is round with
regular border, equal in regular border, equal in
size. size.
Ears are equal in size, Ears are equal in size,
auricle aligns with the auricle aligns with the
corner of each eye, skin is corner of each eye, skin is
smooth with no lesions, smooth with no lesions,
lumps, or nodules. Auricle, lumps, or nodules. Auricle,
tragus, and mastoid tragus, and mastoid
Ears process is not tender. No process is not tender. No
discharges noted upon discharges noted upon
inspection. inspection.

Color is the same of the Color is the same of the

face, nasal structure is face, nasal structure is
smooth and symmetric, no smooth and symmetric, no
tenderness reported from tenderness reported from
the client. Client is able to the client. Client is able to
sniff through each nostril sniff through each nostril
Nose & Sinuses while other side is while other side is
occluded. Nasal mucosa is occluded. Nasal mucosa is
dark pink, moist, and free dark pink, moist, and free
of exudate, nasal septum is of exudate, nasal septum is
intact and free of ulcers. intact and free of ulcers.
Fontal and maxillary Fontal and maxillary
sinuses are nontender to sinuses are nontender to
palpation. Sinuses are not palpation. Sinuses are not
tender to percussion. tender to percussion.
Lips are smooth and moist Lips are smooth and moist
without lesions or swelling, without lesions or swelling,
no decayed areas; two no decayed areas; two
molars missing. Jaws are molars missing. Jaws are
aligned with no deviation aligned with no deviation
seen when biting down. seen when biting down.
Color and consistency of Color and consistency of

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 Mouth & Throat cheeks and gums are cheeks and gums are
even. Gums are pink, moist even. Gums are pink, moist
and firm with tight margins and firm with tight margins
to the tooth. No lesions or to the tooth. No lesions or
masses. Tongue is pink masses. Tongue is pink
and moist, moderate size and moist, moderate size
with papillae, no lesions with papillae, no lesions
are present. Tongue offers are present. Tongue offers
strong resistance, and can strong resistance, and can
distinguish between salty distinguish between salty
and sweet. Uvula is fleshy, and sweet. Uvula is fleshy,
hangs freely in midline. hangs freely in midline.
Throat is pink, without Throat is pink, without
exudate or lesions. exudate or lesions.
Scapula are symmetric and Scapula are symmetric and
non-protruding. Shoulders non-protruding. Shoulders
and scapula are at equal and scapula are at equal
horizontal positions. Client horizontal positions. Client
does not use accessory does not use accessory
muscles to assist muscles to assist
Lungs & Thorax breathing. Examiner finds breathing. Examiner finds
no palpable crepitus. No no palpable crepitus. No
adventitious sounds such adventitious sounds such
as crackles are as crackles are
auscultated. Sternum is auscultated. Sternum is
positioned at the midline positioned at the midline
straight. straight.

Texture is smooth with no Texture is smooth with no

edema. Linear stretch edema. Linear stretch
marks are visible, areolas marks are visible, areolas
are dark, round and big. are dark, round and big.
Nipples are everted, no Nipples are everted, no
discharge present, no sign discharge present, no sign
Breast & Axillae of dimpling or retraction. of dimpling or retraction.
Breasts hangs freely and Breasts hangs freely and
symmetrically, no mass symmetrically, no mass
was palpated, no rash or was palpated, no rash or
infection noted on axillae, infection noted on axillae,
no palpable nodules, no palpable nodules,
discrete, nontender, discrete, nontender,
movable nodes in the movable nodes in the
central area. central area.
No murmurs are heard No murmurs are heard
during auscultation. Heart during auscultation. Heart
rate 120bpm. rate 120bpm.

Heart

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 Referred pain in the lower Referred pain in the lower
abdomen with guarding. abdomen with guarding.
Abdominal skin is pale than Abdominal skin is pale than
general skin tone, general skin tone,
scattered fine veins is scattered fine veins is
visible, abdomen is free of visible, abdomen is free of
rashes or lesions, rashes or lesions,
umbilicus is midline at umbilicus is midline at
Abdomen lateral line, abdomen is lateral line, abdomen is
rounded, symmetric, no rounded, symmetric, no
friction rub over liver or friction rub over liver or
spleen present, dullness spleen present, dullness
was elicited during was elicited during
palpation, no palpable palpation, no palpable
masses are present, liver is masses are present, liver is
not palpable. not palpable.

Have not defecated within Have not defecated within

the shift the shift
No edema present No edema present
Bowel sound is present Bowel sound is present

Gastrointestinal/
Nutrition

Posture is erect, jaw has Posture is erect, jaw has

full ROM against full ROM against
resistance, cervical and resistance, cervical and
lumbar spine are concave, lumbar spine are concave,
nontender spinous nontender spinous
process, firm and smooth. process, firm and smooth.
Shoulders are Shoulders are
symmetrically round, no symmetrically round, no
Musculoskeletal redness, no swelling, or redness, no swelling, or
deformity or heat. Client deformity or heat. Client
can flex, extend, adduct, can flex, extend, adduct,
abduct, rotate, and shrug abduct, rotate, and shrug
shoulders against shoulders against

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 resistance. Elbows are resistance. Elbows are
symmetric, without symmetric, without
deformities, redness or deformities, redness or
swelling. Wrists are swelling. Wrists are
symmetric, without redness symmetric, without redness
or swelling. No tenderness or swelling. No tenderness
palpated in anatomic palpated in anatomic
snuffbox. Hands and snuffbox. Hands and
fingers are symmetric, fingers are symmetric,
nontender and without nontender and without
nodules. nodules.
Pubic hair is evenly Pubic hair is evenly
distributed, no enlargement distributed, no enlargement
or swelling in the inguinal or swelling in the inguinal
lymph nodes, vaginal wall lymph nodes, vaginal wall
is smooth and client reports is smooth and client reports
no tenderness. no tenderness.
Genitourinary

Client correctly identifies Client correctly identifies

scent presented to each scent presented to each
nostril, eyes move in nostril, eyes move in
smooth, coordinated smooth, coordinated
motion. Client smiles, motion. Client smiles,
frowns, wrinkles forehead, frowns, wrinkles forehead,
Neurologic shows teeth, puffs out shows teeth, puffs out
cheeks, purses lip, raises cheeks, purses lip, raises
eyebrows, and closes eyes eyebrows, and closes eyes
against resistance. Client against resistance. Client
swallow difficulty. Tongue swallow difficulty. Tongue
movement is symmetric movement is symmetric
and smooth, bilateral and smooth, bilateral
strength is apparent. strength is apparent.

BUBBLE-HEE ASSESSMENT

Instruction: Please write your focused assessment on the specific areas for
obstetric and gynecologic assessment. Be sure to categorize your findings into
IPPA (Inspection, Palpation, Percussion and Auscultation) format.

Assessment Area 1st Day 2nd Day

No redness of breast No redness of breast
tissue, heat, pain. tissue, heat, pain.

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 BREASTS
feeding method (if
breast feeding, state
frequency, duration),
bra, appearance,
palpation, nipples

Slightly enlarge uterus Slightly enlarge uterus

UTERUS
fundus, diastasis recti
(vaginal birth only),
tenderness, C/S
dressing/ incision,
binder

Bladder is distended Bladder is distended

Urinalysis Urinalysis
 Yellow (Color)  Yellow (Color)
 Slightly Cloudy  Slightly Cloudy
 pH 6.0  pH 6.0
 Specific Gravity  Specific Gravity
BLADDER 1.025 1.025

Bladder distension,
voiding adequately, or
Foley output, S/Sx of
infection

Bowel sounds are heard Bowel sounds are heard

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 during auscultation. during auscultation.

Did not defecate within Did not defecate within

shift. shift.

BOWEL
Bowel sounds, passing
flatus (C/S), BM

No lochial discharges No lochial discharges

LOCHIA
Amount, color, odor,
clots

No signs of DVT while No signs of DVT while

doing dorsiflexion. doing dorsiflexion.

No edema or extremity. No edema or extremity.

EXTREMITY
Edema, pedal
pulses, capillary Pedal pulses are present. Pedal pulses are present.
refill, signs &
symptoms of DVT
(redness, pain,
increased skin
temperature,
unilateral swelling)

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 Abdominal pain degree is Abdominal pain degree is
10/10 10/10

HOMAN’S SIGN
Degree of pain, calf
circumference,
color, capillary refill

No laceration found No laceration found

No hemorrhoids No hemorrhoids
EPISIOTOMY
Degree of
laceration,
perineum (REEDA –
Redness, Edema,
Ecchymosis, Drainage,
Approximation),
comfort measures,
Kegels;
HEMORRHOIDS –
pain, comfort
measures

Patient feels abdominal Patient feels abdominal

pain. pain.

Pain scale 10/10. Pain scale 10/10.

Feels nauseated and Feels nauseated and

drowsy. drowsy.
EMOTIONAL
LABILITY
Facial grimace on guarding Facial grimace on guarding
position. position.

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CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 17 | Page
 DIAGNOSTICS & LABORATORY PROCEDURES & NURSING RESPONSIBILITIES

DIAGNOSTIC INDICATIONS & RESULTS/ NORMAL VALUES NURSING

PROCEDURE PURPOSES RESPONSIBILITIES
INTERPRETATION
A test that is done in Color: Yellow Yellow or Light-yellow Instruct patient to void mid-
order to analyze urine to stream catch of specimen
look for abnormalities such Transparency: Slightly in a dry container.
URINALYSIS as an excess amount of Cloudy
protein, blood, pus, Straw yellow color Collect specimens from
bacteria and sugar. infants and young children
pH: 6.0
4.5 – 8.0 into a disposable collection
Specific Gravity: 1.025 apparatus consisting of a
1.005 to 1.025 plastic bag.
Cover all specimens tightly,
label properly and send
immediately to the
laboratory.
Observe standard
precautions when handling
urine specimens.
If the specimen cannot be
delivered to the laboratory
or tested within an hour, it
should be refrigerated or
have an appropriate
preservative added.

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 To monitor overall health WBC count – 12.6 Explain the test procedure.
part of a routine check-up,
RBC count – 2.43 3.8-5.5 Explain slightly discomfort
and helps to detect variety
of disorders including may be felt.
Hemoglobin – 6.6 12.0-15.2 gm/dL
infections, anemia, Encourage the patient to
CBC diseases of the immune Hematocrit – 19.9 37-46%
avoid stress.
(Complete Blood Count) system, and blood cancer.
Explain that fasting is not
necessary.
Apply manual pressure to
the site.
Monitor the punctured site.
which identifies and Pus Cells: 20-30 / hpf To collect and label
counts the type of cells, casts, specimen for analysis and
crystals, and other To ensure their delivery to
components such as bacteria the lab.
Microscopic Red Blood Cells: 30 / hpf
and mucus that can be
present in urine.

Epithelial Cells: Moderate

Bacteria: Moderate

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 DIAGNOSTICS & LABORATORY PROCEDURES & NURSING RESPONSIBILITIES

DIAGNOSTIC INDICATIONS & RESULTS/ NORMAL VALUES NURSING

PROCEDURE PURPOSES RESPONSIBILITIES
INTERPRETATION

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 MEDICAL MANAGEMENT & NURSING RESPONSIBILITIES

Instructions: Fill – out the necessary information required on the tables.

I. Intravenous Fluid Therapy and Nursing Responsibilities
Intravenous Fluids General Description Indication or Purpose Nursing Responsibilities
D5LriL (Dextrose 5% D5Lr is a sterile, non-pyrogenic Treatment for persons needing extra Do not administer unless solution is
in Lactated Ringer’s) solution for fluid and electrolyte calories who cannot tolerate fluid clean and container is undamaged.
replenishment and calorie supply in a overload.
single dose containers for intravenous Caution must be exercised in the
administration. administration of parenteral fluids.

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 Discard unused portion.

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II. Pharmacotherapy & Nursing Responsibilities

Drug Mechanism of Indications or Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Action Purpose
Generic Name: Provides Supplies iron to Contraindicated in GI: nausea, pain, Constipation, GI upset may be related to
elemental the body which is patients with vomiting, contact irritation, dose.
iron, an needed to help primary constipation, diarrhea, dark
Ferrous essential your blood carry hemochromatosis diarrhea, black stools, nausea, Between meal doses are
Fumarate component in oxygen to your or hemosiderosis, stools, anorexia stomach pain, urine preferable, but drug can be
the formation organs. hemolytic anemia, discoloration, given with some foods,
of peptic ulcer vomiting although absorption may be
hemoglobin. disease, regional decreased.
enteritis, or
Brand Name: ulcerative colitis. Check for constipation,
record color and amount of
stools.

Alert: Oral iron may turn

stools black, this
Classification:
unabsorbed iron is
harmless, it could mask
Iron supplement
presence of melenia.

Dose, Route & Monitor hemoglobin level,

Timing: hematocrit, and reticulocyte
count during therapy.
Adults: 100 to
200mg PO
elemental iron

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daily in three
divided doses

Drug Mechanism of Indications or Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Action Purpose
Generic Name: Methotrexate Ectopic pregnancy Known allergic Nausea or vomiting Dizziness Monitor client taking
works by hypersensitivity to Stomach pain or Drowsiness Methotrexate for: abdominal
stopping the the drug. upset Headaches pain, diarrhea or ulcerative
Methotrexate growth of the Diarrhea Malaise stomatitis (therapy may be
fertilized egg Pregnancy Hair loss Anorexia discontinued with the
before a Tiredness Nausea and presence of these toxic
rupture Dizziness vomiting effects otherwise,
occurs. Chills Hepatoxicity hemorrhagic enteritis and
Brand Name: Sometimes, Headache Alopecia death from intestinal
Maxtrex methotrexate Ulcerative stomatitis perforation may occur).
is combined Leukopenia
with surgery Chills and fever Symptoms of pulmonary
Classification: to treat at Photosensitivity toxicity, which may manifest
ectopic Thrombocytopenia early as a dry and
Antineoplastic pregnancy. In Hyperurecemia nonproductive cough.
this case, the
Dose, Route & medicine Symptoms of gout due to
Timing: removes fetal increased uric acid, (edema,
cells left joint pain).
PO/IM (adults): behind after
20-30 mg/m2 surgery. Laboratory Tests:
twice weekly for  CBC (WBC and
the Platelet)
maintenance  Renal function (BUN
phase of the and Creatinine)

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therapy.  Hepatic function
(AST, ALT, bilirubin)
Serum Uric Acid
concentration

Drug Mechanism of Indications or Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Action Purpose
Generic Name: May block pain Relieves minor Contraindicated to Nausea, stomach CNS: stimulation, Administer to patient crushed
impulses aches and pains. patient pain, loss of appetite, drowsiness or whole, chewable tabs may
peripherally that hypersensitive to itching, rash, be chewed; do not crush or
Acetaminophen
occur in response the drug and its headache, dark urine, GI: abdominal pain, chew. Give with food or milk to
to inhibition of component. clay-colored stools, hepatoxicity, hepatic decrease gastric symptoms;
prostaglandin jaundice (yellowing of seizure (overdose) give 30 minutes before or 2
Brand Name: synthesis; does skin or eyes). GI bleeding hours after meals.
not possess anti-
inflammatory GU: renal failure Assess type of pain, location,
properties. (high prolonged intensity, duration, and
Classification: dose) diaphoresis.

Hema: Assess for rapid weak pulse,

Analgesic Thrombocytopenia, dyspnea, cold, clammy
leucopenia, extremities, report immediately
neutropenia, to healthcare provider.
Dose, Route & hemolytic anemia,
Timing: pancytopenia Assess for hepatoxicity, dark
urine, clay-colored stools,
Oral, Integ: rash, urticaria yellowing of skin and sclera,
immediate- itching, abdominal pain, and
release: 325 mg System: diarrhea.
hypersensitivity
to 1 g orally
Monitor renal function: BUN,
every 4 to 6 Toxicity: cyanosis, creatinine, occult blood,
hours anemia, neutropenia, albumin.
jaundice,
pancytopenia, CNS Monitor blood: CBC, platelet.

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 25 | Page
 stimulation, seizures

DIET & ACTIVITY MANAGEMENT & NURSING RESPONSIBILITIES

Type of Diet/Activity General Description Indication or Purposes Restricted Foods/Activities Nursing Responsibilities
This diet is only given when client Maintain or restore good Strenuous activities, sexual Explain treatment regime;
can now tolerate any food nutritional status. intercourse, alcohol, fortified advocate for more detailed
she desires that is cereals, enriched bread and explanation particularly on
Diet as Tolerated nutritious, if this will not lead pasta, peanuts, beans, diet prescriptions.
To afford rest to a particular part of
to any complications and if orange juice.
the body that may have
the client needs further Assess patient’s tolerance
been affected by illness or
monitoring for lab test. to food given.
surgery.
Have patient sit upright
when eating or drinking.

Make sure that the given

food is appropriate to the
diet of the patient.

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 26 | Page
CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 27 | Page
 MONITORING SHEET

Instructions: Fill – out the necessary data on vital signs monitoring and intake
and output sheet accordingly.

A. Vital Signs Monitoring

Shift: ______________

Date & Temp HR/PR RR BP O2 Sat

Time
03/26/20 35.9 C 120 bpm N/A 90/50mmH
g
6:00 am

B. Intake & Output Monitoring

Shift: ______________

Date & Intake Output

Time
IV IVT P Others Total Urine Stool Others Total
F T O
10 1000
00 cc
cc

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 28 | Page
 TOTAL INTAKE 1000 TOTAL OUTPUT
cc
TPR SHEET
(Please attach here)

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 29 | Page
CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 30 | Page
 Instructions: Fill – out the table below with the appropriate nursing diagnosis and make your nursing care plan utilizing the nursing process.
NURSING PROCESS RECORD
Patient’s Name : HRN 143
Medical Diagnosis : Ruptured Ectopic Pregnancy
NANDA Nursing Diagnosis: Risk for Deficient Fluid Volume related to bleeding from a ruptured ectopic pregnancy. Domain 2, Class 5, Code 00027

NANDA Definition: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in
sodium.
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION (NOC) INTERVENTIONS
RATIONALE EVALUATION
CLASSIFICATION (NIC)
Objective:  Assess client history of  Estimation of the volume of Client will demonstrate
Client will blood loss (amount, blood loss aids in the improvement in fluid balance
Patient is pale on demonstrate duration, characteristics, differential diagnosis. A one as evidenced by stable vital
physical examination, improvement in and presence of clot). gram of pad weight is equal signs, good capillary refill,
fluid balance as Instuct pad count; weigh to approximately 1 ml of absence of alteration
decreased skin evidenced by stable vital pads/underpad. blood loss. sensorium, and individually
turgor. signs, good capillary refill, adequate urine output and
absence of alteration  Monitor uterine activity, specific gravity.
sensorium, and fetal status, and any  Helps determine nature of
individually adequate abdominal tenderness. the hemorrhage and possible
urine output and specific outcome of a hemorrhagic
gravity. episode. Tenderness is
Subjective: usually present in ruptured
ectopic pregnancy or
Patient verbalized abruptio placentae.
she feels nauseated
and dizzy whenever
she sits up.  Reflects the extent of blood

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 31 | Page
 loss, although cyanosis and
changes in BP and pulse are
 Monitor vital signs,
late signs of circulatory loss
capillary refill, color of
and developing shock.
mucous membranes/skin.
Measure CVP, if feasible.
 Determines the degree of
fluid losses and reflects the
adequacy of renal perfusion.
 Record intake/output.
Obtain hourly urine
samples; measure specific
gravity.  Promotes the occurrence of
hemorrhage, especially if
marginal or total placenta
 Discourage rectal or previa is considered.
vaginal examination.

 Ensures adequate blood

available to the brain.
Elevating hips avoids
compression of the vena
 Position client cava, while semi-Fowler’s
appropriately, either position allows the fetus to
supine with hips elevated act as a tampon, controlling
or in semi-Fowler’s bleeding in placenta previa.
position for placenta Trendelenburg position may
previa. Avoid compromise maternal
Trendelenburg position. respiratory status.

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 32 | Page
  Determines the amount of
blood loss and may provide
information regarding the
cause. Hct should be
maintained above 30% to
support oxygen and nutrient
transport.

 Monitor laboratory reports

such as CBC, type and
crossmatch, Rh titer,
fibrinogen levels, platelet
count, APTT, PT, and HCG
levels.
Reference/s: Nanda 2018- 2019

NURSING PROCESS RECORD

Patient’s Name : HRN 143
Medical Diagnosis : Ruptured Ectopic Pregnancy
NANDA Nursing Diagnosis: Acute Pain related to rupture of the fallopian tube. Domain 12, Class 1, Code 00132

NANDA Definition: Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such
damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or
predictable end, and with a duration of less than 3 months.
CUES/Defining NURSING OUTCOMES NURSING

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 33 | Page
 Characteristics CLASSIFICATION (NOC) INTERVENTIONS RATIONALE EVALUATION
CLASSIFICATION (NIC)
 Guarding behavior After 8 hours of nursing • Monitor maternal vital • To determine presence of After 8 hours of nursing
 Abdominal Pain interventions, the patient signs. hypotension and tachycardia interventions, the patient was
scale 10/10 will be relieved or caused by rupture or relieved or controlled.
 Facia grimace controlled. hemorrhage.

• To further assess the present

• Monitor for presence and situation indicating
amount of vaginal bleeding. hemorrhage.

• Increased pain and

abdominal distention indicates
• Monitor for increase and rupture and possible intra-
pain and abdominal abdominal hemorrhage.
distention and rigidity.

• To determine the amount of

blood loss.
• Monitor complete blood
count (CBC).
• Promotes relaxation and may
enhance patient’s coping
• Provide comfort measure abilities by refocusing
like back rubs, deep attention.
breathing. Instruct in
relaxation or visualization
exercises. Provide

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 34 | Page
 diversional activities.

Reference/s: Nanda 2018-2020

NURSING PROCESS RECORD
Patient’s Name : HRN 143
Medical Diagnosis : Ruptured Ectopic Pregnancy
NANDA Nursing Diagnosis: Powerlessness related to early loss of pregnancy secondary to ectopic pregnancy Domain 9, Class 2, Code 00152

NANDA Definition: Susceptible to the lived experience of lack of control over situation, including apperception that one’s actions do not
significantly affect the outcome, which may compromise health.
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION (NOC) INTERVENTIONS
RATIONALE EVALUATION
CLASSIFICATION (NIC)
 Anxiety  Patient expresses  Encourage verbalization of  This approach creates a Anxiety is reduced to a
 Abdominal pain sense of personal feelings, thoughts, and supportive environment and considerable extent
10/10 control. concerns about making sends a message of caring.
 Patient displays content decisions.
with life choices.
 Patient recognizes
means to control over  Encourage patient to
personal situation.  This will aid patient to
identify strengths.
 Patient makes choices recognize inner strengths.
free from undue stress
from others.

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 35 | Page
 Discuss with the patient  Allowing the patient to
concerning his or her care participate in discussions will
(e.g., treatment options, increase his or her sense of
convenience of visits, or independence or autonomy.
time of ADLs).

 Help the patient in

 The patient may have his or
reexamining negative
her own perceptions that are
perceptions of the
unrealistic for the situation.
situation.

 Give the patient control

over his or her  This approach enhances
environment. patient’s independence.

 Support in planning and

creating a timetable to
manage increased  Use of realistic short-term
responsibility in the future. goals for resuming aspects of
self-care foster confidence in
one’s abilities.

 Render positive feedback

for making decisions and  Success promotes
engaging in self-care. confidence in abilities and a
sense of control. Recognition
and positive reinforcement
for self-care are great
motivators for heightening

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 36 | Page
 self-esteem and feelings of
self-governance.
Reference/s: Nanda 2018-2020

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 37 | Page
 BREASTFEEDING OBSERVATION AID

Mother’s HRN: 143_________________________ Date March 26,

2020_____
Baby's HRN : _______________________________ Baby's age ____________

Signs that breastfeeding is going well: Signs of possible difficulty:

GENERAL
Mother: Mother:
⮚ Mother looks healthy ⮚ Mother looks ill or depressed
⮚ Mother relaxed and comfortable / Mother looks tense and uncomfortable
⮚ Signs of bonding between mother and baby ⮚ No mother/baby eye contact
Baby: Baby:
⮚ Baby looks healthy ⮚ Baby looks sleepy or ill
⮚ Baby calm and relaxed ⮚ Baby is restless or crying
⮚ Baby reaches or roots for breast if hungry ⮚ Baby does not reach or root

BREASTS
/ Breasts look healthy ⮚ Breasts look red, swollen, or sore
/ No pain or discomfort ⮚ Breast or nipple painful
/ Breast well supported with fingers away ⮚ Breasts held with fingers on areola
from nipple

BABY’S POSITION
⮚ Baby’s head and body in line ⮚ Baby’s neck and head twisted to feed
⮚ Baby held close to mother’s body ⮚ Baby not held close
⮚ Baby’s whole body supported ⮚ Baby supported by head and neck only
⮚ Baby approaches breast, nose to nipple ⮚ Baby approaches breast, lower lip/chin
to nipple
BABY’S ATTACHMENT
⮚ More areola seen above baby’s top lip ⮚ More areola seen below bottom lip
⮚ Baby’s mouth opens wide ⮚ Baby’s mouth not open wide
⮚ Lower lip turned outwards ⮚ Lips pointing forward or turned in
⮚ Baby’s chin touches breast ⮚ Baby’s chin not touching breast

SUCKLING
⮚ Slow, deep sucks with pauses ⮚ Rapid shallow sucks
⮚ Cheeks round when suckling ⮚ Cheeks pulled in when suckling
⮚ Baby releases breast when finished ⮚ Mother takes baby off the breast
⮚ Mother notices signs of oxytocin reflex ⮚ No signs of oxytocin reflex noticed

Notes: Since the baby was dead was not able to assess it.

Assessed by: ___________Nazareth N. Patindol_____________________

Student’s Signature over Printed Name

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 38 | Page
 Evidence – Based Nursing Research
(Reflection Paper)

Instructions: Search for a research article related to the case of your patient and
give your own reflection/insights.

Working in the hospital opened my eyes to those things we can’t see in

our daily basis. I have seen mothers giving birth and sometimes the outcome
was not expected. Its really hard seeing them in pain but I know after seeing their
child for the first time, the pain will go away. Many emotions and different
perceptions can occur as a response to pregnancy. Some of these emotions
include joy, fear, mood swings, anxiety, financial concerns, depression, and
adverse emotional reactions to the bodily changes of pregnancy.

My patient was 26year old who was diagnosed with ruptured ectopic
pregnancy. An ectopic pregnancy is a medical emergency in which a fertilized
egg implants itself outside the uterus. Usually, an ectopic pregnancy is situated in
one of the fallopian tubes. As it grows, it can cause the tube to tear or burst. This
results in dangerous internal bleeding. An ectopic pregnancy occurs in roughly
one in 100 pregnancies. It is important to know that an ectopic pregnancy is not
able to develop into a healthy pregnancy or baby. The mother must be treated to
avoid risks and complications, such as rupture, that can be life-threatening.
Almost all ectopic pregnancies will require treatment. Treatment options for
ectopic pregnancy currently include medical management or surgery.
Pharmacologic treatment with methotrexate can be used in an early ectopic
pregnancy when there is no risk of imminent rupture. Surgery is needed if the
ectopic pregnancy has ruptured.

Now my patient is recovering from it. I know its hard for her to move on
after seeing her first child die.

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 39 | Page
 LEARNING FEEDBACK DIARY

Learnings Problems Encountered Actions Taken Realization

I have learned so many things The problems I encountered Study your patients’ charts so To be professional. Even
specially in the clinical setting was not mentally prepared. It you’re prepared if you’re called though I’m a student, this is a
in preparation for my future really affects my total on by your clinical instructor to work environment, and basic
career. To be on time and to performance in the clinical answer questions about one of workplace etiquette should be
treat this clinical rotation like setting. them. applied.
Self any other job.

I have learned the value of The problems I encountered To always be professional To listen to one another. You
sharing and camaraderie. was just too little. It is just a because you never knew who can never go wrong in
misunderstanding because I you will encounter in you job listening.
Peers know that it was stressful in someday. You have to adjust
the duty. and compose yourself. To
avoid conflicts.

I have learned to stay positive. The problems I encountered I didn’t mind what my patient Giving up was never an
No matter what my patient was being judged by the said instead, I used it to option. Yes, you can cry as
thinks about my performance. watcher of my patient because improve more what is really much as you like because its
We all need to vent from time they think that I’m not ready in lacking in me. I’m being normal when somebody felt
to time, but do it away from the this kind of job. That I was still positive even though it hurts sad but you should always
Patient’s hospital and on your own time. lacking some skills. sometimes but that is how life remember never to give up.
Area works. You failed then you Try to remember the reason
learn from it. why you took this course in the
first place and used it to gain

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 40 | Page
 strength.
I have learned to love more of The problems I encountered I was able to understand the Stay alert. You never know
my course because of what was not able to all the situation and just be thankful when an opportunity to learn
my clinical instructor had learnings needed since were for the knowledge they shared something new will strike.
Clinical shared to us. to many. to me.
Instructor

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 41 | Page
 WEEK 2
Item Points
GOSO
Clinical Teaching Plan
Morse Fall Scale (Fall Assessment)
Maternal Health Assessment
Review of Systems
Bubble-Hee Assessment
Diagnostic, Laboratory Procedures and its Nursing
Responsibilities
Medical Management and its Nursing Responsibilities
iii. Intravenous Fluid Therapy & NR
iv. Pharmacotherapy & NR
Vital Signs Monitoring
TPR Sheet
Nursing Process Record
Breastfeeding Observation Aid
Evidence – Based Nursing Research (Reflection Paper)
Total

_____________________________________
Clinical Instructor

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 42 | Page
 GENERAL OBJECTIVE AND SPECIFIC OBJECTIVES (GOSO)

HRN : ___________________________________ Date: _______________

Hospital: __________________________________ Shift: _______________
Clinical Instructor: ___________________________ Area: _______________

GENERAL OBJECTIVE
1ST DAY 2ND DAY

SPECIFIC OBJECTIVES
1ST DAY 2ND DAY
Knowledge
3. 1.

4. 2.

Skills
1. 1.

2. 2.

Attitude
1. 1.

2. 2.

CLINICAL TEACHING PLAN

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 43 | Page
 Activities
Time 1ST Day 2ND Day

MORSE FALL SCALE

(Fall Assessment)

HRN: ______________________________ Age: _________ Date: __________

Instruction: Write the score that corresponds to the item being assessed on the
space provided.
Item Item Score Patient Score
7. History of falling (immediate or previous) No 0
Yes 25 ______
8. Secondary diagnosis (≥ 2 medical No 0
diagnosis in chart
Yes 15 ______
9. Ambulatory aid
⮚ None/bedrest/nurse assist 0
⮚ Crutches/cane/walker 15
⮚ furniture 30 ______

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 44 | Page
 10. Intravenous therapy/heparin lock No 0
Yes 20 ______
11. Gait
⮚ Normal/bedrest/wheelchair 0
⮚ Weak* 10
⮚ Impaired* 20 ______
12. Mental status
⮚ Oriented to own ability 0
⮚ Overestimates/forgets limitations 15 ______
TOTAL:
Interpretation: Tally the patient score and record.
<25 : Low risk
25-45 : Moderate risk
>45 : High risk

Note:
⮚ Weak Gait: Short steps (may shuffle), stooped but able to lift head while walking, may
seek support from furniture while walking, but with light touch (for reassurance).
⮚ Impaired gait: Short steps with shuffle; may have difficulty arising from chair; head down;
significantly impaired balance, requiring furniture, support person, or walking aid to walk.
⮚ Suggested scoring based on Morse JM, Black C, Oberle K, et al. A prospective study to
identify the fall-prone patient. Soc Sci Med 1989; 28(1):81-6. However, note that Morse
herself said that the appropriate cut-points to distinguish risk should be determined by
each institution based on the risk profile of its patients. For details, see Morse JM, Morse
RM, Tylko SJ. Development of a scale to identify the fall-prone patient. Can J
Aging 1989;8;366-7.

MATERNAL HEALTH ASSESSMENT

Instructions: Kindly fill-out the forms with the necessary information of the
patient. Write legibly and accurately.

I. PATIENT’S PROFILE

HRN : Age:

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 45 | Page
Birth Date : Sex:
Civil Status : Religion:
Address : Height:
Educational Attainment : Weight:
Occupation : Blood Type

Ethnic Group : Vital Signs

Date & Time of Admission: BP:
Attending Physician : RR:
Medical Diagnosis : PR:
Temp:
History of Allergy/ies :

Delivery Details :

Type of Delivery :
Medications (if given)

Date of Delivery : Time:

Episiotomy Type : Estimated blood loss:

Degree of Laceration: Type of Placenta:

II. OBSTETRIC HISTORY

LMP: _______________ G: ___ P: ___ (T: ___, P: ___, A: ___, L: ___)
EDC: _______________
AOG: _______________
Age of Menarche: ________________ Menstrual Cycle: _______ days
Duration : ________________

Gravid Place of Delivery Manner of Presentatio Complication

a Delivery n s
AOG

G1
G2
G3
G4
G5
G6
G7

III. OBSTETRIC RISK FACTORS

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 46 | Page
 [ ] Age (below 18 and above 35) [ ] Multiple Pregnancy

[ ] Ovarian Cyst [ ] Uterine Myoma [ ] Placenta previa

[ ] History of still birth [ ] History of 3 Miscarriages
[ ] History of pre-eclampsia/eclampsia [ ] Others: (please specify)
_____
___________________________________________________________
IV. ANTENATAL HISTORY

Variables 1ST TRIMESTER 2ND TRIMESTER 3RD TRIMESTER

Number of
Visits

Signs &
Symptoms of
Pregnancy

Diagnostic/s &
Laboratory
Test/s Result

Immunization/
s Given

Medication/s
Taken

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 47 | Page
V. FAMILY HEALTH HISTORY
[ ] Diabetes [ ] Asthma [ ] HPN [ ] Allergy
[ ] Bleeding disorder [ ] Mental Disorder [ ] Heart disease [ ] Epilepsy

[ ] Others: __________________________________________________

VI. PAST HEALTH HISTORY

Medical History: Hospitalized? [ ] Yes [ ] No
If Yes, when?____________________
Reason of hospitalization:
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________

Surgical History: [ ] Yes [ ] No

If Yes, when? ___________________
Reason and type of Surgery
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
VII. FAMILY PLANNING METHOD HISTORY
C. Natural Method
[ ] Calendar Method [ ] Abstinence [ ] Withdrawal
[ ] Cervical Mucus [ ] Basal Body Temperature
[ ] Standard Days Method [ ] Lactational Amenorrhea Method
[ ] Others: _____________________________________________

D. Artificial Method
[ ] IUD [ ] Pills [ ] Injectable (DEPO) [ ] Condom
[ ] Bilateral Tubal Ligation (BTL) [ ] Intradermal Implant
[ ] Others: _____________________________________________

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 48 | Page
 REVIEW OF SYSTEMS

Instructions: Kindly accomplish this matrix. Be sure to fill out with normal and
abnormal findings. Follow the IPPA or IAPP (Inspection, Percussion, Palpation
and Auscultation) format. Note: *Only for systems that are applicable
BODY 1ST DAY 2ND DAY
PART/SYSTEM

General Survey/
Mental Status

Integumentary

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 49 | Page
 Head & Face

Neck

Eyes

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 50 | Page
 Ears

Nose & Sinuses

Mouth & Throat

Lungs & Thorax

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 51 | Page
 Breast & Axillae

Heart

Abdomen

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 52 | Page
Gastrointestinal/
Nutrition

Musculoskeletal

Genitourinary

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 53 | Page
 Neurologic

BUBBLE-HEE ASSESSMENT

Instruction: Please write your focused assessment on the specific areas for
obstetric and gynecologic assessment. Be sure to categorize your findings into
IPPA (Inspection, Palpation, Percussion and Auscultation) format.

Assessment Area 1st Day 2nd Day

BREASTS
feeding method (if
breast feeding, state
frequency, duration),
bra, appearance,
palpation, nipples

UTERUS
fundus, diastasis recti
(vaginal birth only),
tenderness, C/S
dressing/ incision,
binder

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 54 | Page
 BLADDER
Bladder distension,
voiding adequately, or
Foley output, S/Sx of
infection

BOWEL
Bowel sounds, passing
flatus (C/S), BM

LOCHIA
Amount, color, odor,
clots

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 55 | Page
 EXTREMITY
Edema, pedal
pulses, capillary
refill, signs &
symptoms of DVT
(redness, pain,
increased skin
temperature,
unilateral swelling)

HOMAN’S SIGN
Degree of pain, calf
circumference,
color, capillary refill

EPISIOTOMY
Degree of
laceration,
perineum (REEDA –
Redness, Edema,

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 56 | Page
Ecchymosis, Drainage,
Approximation),
comfort measures,
Kegels;
HEMORRHOIDS –
pain, comfort
measures

EMOTIONAL
LABILITY

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 57 | Page
 DIAGNOSTIC, LABORATORY PROCEDURES & NURSING RESPONSIBILITIES

DIAGNOSTIC INDICATIONS & RESULTS/ NORMA

PROCEDURE PURPOSES
INTERPRETATION

DIAGNOSTICS & LABORATORY PROCEDURES & NURSING RESPONSIBILITIES

DIAGNOSTIC INDICATIONS & RESULTS/ NORMA

PROCEDURE PURPOSES

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 58 | Page
 INTERPRETATION

MEDICAL MANAGEMENT & NURSING RESPONSIBILITIES

Instructions: Fill – out the necessary information required on the tables.

I. Intravenous Fluid Therapy and Nursing Responsibilities
Intravenous Fluids General Description Indication or Purpose

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 59 | Page
II. Pharmacotherapy & Nursing Responsibilities

Drug Mechanism of Indications or Contraindications Side Effects A

Action Purpose
Generic Name:

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 60 | Page
Brand Name:

Classification:

Dose, Route &

Timing:

Drug Mechanism of Indications or Contraindications Side Effects A

Action Purpose
Generic Name:

Brand Name:

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 61 | Page
Classification:

Dose, Route &

Timing:

Drug Mechanism of Indications or Contraindications Side Effects A

Action Purpose
Generic Name:

Brand Name:

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 62 | Page
Classification:

Dose, Route &

Timing:

DIET & ACTIVITY MANAGEMENT & NURSING RESPONSIBILITIES

Type of Diet/Activity General Description Indication or Purposes Restricted Fo

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 63 | Page
CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 64 | Page
 MONITORING SHEET

Instructions: Fill – out the necessary data on vital signs monitoring and intake
and output sheet accordingly.

A. Vital Signs Monitoring

Shift: ______________

Date & Temp HR/PR RR BP O2 Sat

Time

B. Intake & Output Monitoring

Shift: ______________

Date & Intake Output

Time
IV IVT P Others Total Urine Stool Others Total
F T O

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 65 | Page
 TOTAL INTAKE TOTAL OUTPUT
TPR SHEET
(Please attach here)

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 66 | Page
CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 67 | Page
Instructions: Fill – out the table below with the appropriate nursing diagnosis and make your nursing care plan
utilizing the nursing process. NURSING PROCESS RECORD
Patient’s Name :
______________________________________________________________________
______________________________
Medical Diagnosis :
______________________________________________________________________
______________________________
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION (NOC) INTERVENTIONS
RATIONA
CLASSIFICATION (NIC)

Reference/s:
______________________________________________________________________
_____________________________________
NURSING PROCESS RECORD

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 68 | Page
Patient’s Name :
______________________________________________________________________
______________________________
Medical Diagnosis :
______________________________________________________________________
______________________________
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION (NOC) INTERVENTIONS
RATIONA
CLASSIFICATION (NIC)

Reference/s:
______________________________________________________________________
_____________________________________
NURSING PROCESS RECORD

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 69 | Page
Patient’s Name :
______________________________________________________________________
______________________________
Medical Diagnosis :
______________________________________________________________________
______________________________
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION (NOC) INTERVENTIONS
RATIONA
CLASSIFICATION (NIC)

Reference/s:
______________________________________________________________________
_____________________________________

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 70 | Page
 BREASTFEEDING OBSERVATION AID

Mother’s HRN : _________________________ Date _________________

Baby's HRN : _______________________________ Baby's age ____________

Signs that breastfeeding is going well: Signs of possible difficulty:

GENERAL
Mother: Mother:
⮚ Mother looks healthy ⮚ Mother looks ill or depressed
⮚ Mother relaxed and comfortable ⮚ Mother looks tense and uncomfortable
⮚ Signs of bonding between mother and baby ⮚ No mother/baby eye contact
Baby: Baby:
⮚ Baby looks healthy ⮚ Baby looks sleepy or ill
⮚ Baby calm and relaxed ⮚ Baby is restless or crying
⮚ Baby reaches or roots for breast if hungry ⮚ Baby does not reach or root

BREASTS
⮚ Breasts look healthy ⮚ Breasts look red, swollen, or sore
⮚ No pain or discomfort ⮚ Breast or nipple painful
⮚ Breast well supported with fingers away ⮚ Breasts held with fingers on areola
from nipple

BABY’S POSITION
⮚ Baby’s head and body in line ⮚ Baby’s neck and head twisted to feed
⮚ Baby held close to mother’s body ⮚ Baby not held close
⮚ Baby’s whole body supported ⮚ Baby supported by head and neck only
⮚ Baby approaches breast, nose to nipple ⮚ Baby approaches breast, lower lip/chin
to nipple
BABY’S ATTACHMENT
⮚ More areola seen above baby’s top lip ⮚ More areola seen below bottom lip
⮚ Baby’s mouth opens wide ⮚ Baby’s mouth not open wide
⮚ Lower lip turned outwards ⮚ Lips pointing forward or turned in
⮚ Baby’s chin touches breast ⮚ Baby’s chin not touching breast

SUCKLING
⮚ Slow, deep sucks with pauses ⮚ Rapid shallow sucks
⮚ Cheeks round when suckling ⮚ Cheeks pulled in when suckling
⮚ Baby releases breast when finished ⮚ Mother takes baby off the breast
⮚ Mother notices signs of oxytocin reflex ⮚ No signs of oxytocin reflex noticed

Notes:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Assessed by: _________________________________________

Student’s Signature over Printed Name

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 71 | Page
 Evidence – Based Nursing Research
(Reflection Paper)

Instructions: Search for a Research Article related to the case of your patient
and give your own reflection/insights.

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 72 | Page
 LEARNING FEEDBACK DIARY

Learnings Problems Encountered Actions Ta

Self

Peers

Patient’s
Area

Clinical
Instructor

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 73 | Page
 WEEK 3
Item Points
GOSO
Clinical Teaching Plan
Morse Fall Scale (Fall Assessment)
Maternal Health Assessment
Review of Systems
Bubble-Hee Assessment
Diagnostic, Laboratory Procedures and its Nursing
Responsibilities
Medical Management and its Nursing Responsibilities
v. Intravenous Fluid Therapy & NR
vi. Pharmacotherapy & NR
Vital Signs Monitoring
TPR Sheet
Nursing Process Record
Breastfeeding Observation Aid
Evidence – Based Nursing Research (Reflection Paper)
Total

_____________________________________
Clinical Instructor

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 74 | Page
 GENERAL OBJECTIVE AND SPECIFIC OBJECTIVES (GOSO)

HRN : ___________________________________ Date: _______________

Hospital: __________________________________ Shift: _______________
Clinical Instructor: ___________________________ Area: _______________

GENERAL OBJECTIVE
1ST DAY 2ND DAY

SPECIFIC OBJECTIVES
1ST DAY 2ND DAY
Knowledge
5. 1.

6. 2.

Skills
3. 1.

4. 2.

Attitude
3. 1.

4. 2.

CLINICAL TEACHING PLAN

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 75 | Page
 Activities
Time 1ST Day 2ND Day

MORSE FALL SCALE

(Fall Assessment)

HRN: ______________________________ Age: _________ Date: __________

Instruction: Write the score that corresponds to the item being assessed on the
space provided.
Item Item Score Patient Score
13. History of falling (immediate or previous) No 0
Yes 25 ______
14. Secondary diagnosis (≥ 2 medical No 0
diagnosis in chart
Yes 15 ______
15. Ambulatory aid
⮚ None/bedrest/nurse assist 0
⮚ Crutches/cane/walker 15
⮚ furniture 30 ______

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 76 | Page
 16. Intravenous therapy/heparin lock No 0
Yes 20 ______
17. Gait
⮚ Normal/bedrest/wheelchair 0
⮚ Weak* 10
⮚ Impaired* 20 ______
18. Mental status
⮚ Oriented to own ability 0
⮚ Overestimates/forgets limitations 15 ______
TOTAL:
Interpretation: Tally the patient score and record.
<25 : Low risk
25-45 : Moderate risk
>45 : High risk

Note:
⮚ Weak Gait: Short steps (may shuffle), stooped but able to lift head while walking, may
seek support from furniture while walking, but with light touch (for reassurance).
⮚ Impaired gait: Short steps with shuffle; may have difficulty arising from chair; head down;
significantly impaired balance, requiring furniture, support person, or walking aid to walk.
⮚ Suggested scoring based on Morse JM, Black C, Oberle K, et al. A prospective study to
identify the fall-prone patient. Soc Sci Med 1989; 28(1):81-6. However, note that Morse
herself said that the appropriate cut-points to distinguish risk should be determined by
each institution based on the risk profile of its patients. For details, see Morse JM, Morse
RM, Tylko SJ. Development of a scale to identify the fall-prone patient. Can J
Aging 1989;8;366-7.

MATERNAL HEALTH ASSESSMENT

Instructions: Kindly fill-out the forms with the necessary information of the
patient. Write legibly and accurately.

I. PATIENT’S PROFILE

HRN : Age:

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 77 | Page
Birth Date : Sex:
Civil Status : Religion:
Address : Height:
Educational Attainment : Weight:
Occupation : Blood Type

Ethnic Group : Vital Signs

Date & Time of Admission: BP:
Attending Physician : RR:
Medical Diagnosis : PR:
Temp:
History of Allergy/ies :

Delivery Details :

Type of Delivery :
Medications (if given)

Date of Delivery : Time:

Episiotomy Type : Estimated blood loss:

Degree of Laceration: Type of Placenta:

II. OBSTETRIC HISTORY

LMP: _______________ G: ___ P: ___ (T: ___, P: ___, A: ___, L: ___)
EDC: _______________
AOG: _______________
Age of Menarche: ________________ Menstrual Cycle: _______ days
Duration : ________________

Gravid Place of Delivery Manner of Presentatio Complication

a Delivery n s
AOG

G1
G2
G3
G4
G5
G6
G7

III. OBSTETRIC RISK FACTORS

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 78 | Page
 [ ] Age (below 18 and above 35) [ ] Multiple Pregnancy

[ ] Ovarian Cyst [ ] Uterine Myoma [ ] Placenta previa

[ ] History of still birth [ ] History of 3 Miscarriages
[ ] History of pre-eclampsia/eclampsia [ ] Others: (please specify)
_____
___________________________________________________________
IV. ANTENATAL HISTORY

Variables 1ST TRIMESTER 2ND TRIMESTER 3RD TRIMESTER

Number of
Visits

Signs &
Symptoms of
Pregnancy

Diagnostic/s &
Laboratory
Test/s Result

Immunization/
s Given

Medication/s
Taken

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 79 | Page
V. FAMILY HEALTH HISTORY
[ ] Diabetes [ ] Asthma [ ] HPN [ ] Allergy
[ ] Bleeding disorder [ ] Mental Disorder [ ] Heart disease [ ] Epilepsy

[ ] Others: __________________________________________________

VI. PAST HEALTH HISTORY

Medical History: Hospitalized? [ ] Yes [ ] No
If Yes, when?____________________
Reason of hospitalization:
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________

Surgical History: [ ] Yes [ ] No

If Yes, when? ___________________
Reason and type of Surgery
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
VII. FAMILY PLANNING METHOD HISTORY
E. Natural Method
[ ] Calendar Method [ ] Abstinence [ ] Withdrawal
[ ] Cervical Mucus [ ] Basal Body Temperature
[ ] Standard Days Method [ ] Lactational Amenorrhea Method
[ ] Others: _____________________________________________

F. Artificial Method
[ ] IUD [ ] Pills [ ] Injectable (DEPO) [ ] Condom
[ ] Bilateral Tubal Ligation (BTL) [ ] Intradermal Implant
[ ] Others: _____________________________________________

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 80 | Page
 REVIEW OF SYSTEMS

Instructions: Kindly accomplish this matrix. Be sure to fill out with normal and
abnormal findings. Follow the IPPA or IAPP (Inspection, Percussion, Palpation
and Auscultation) format. Note: *Only for systems that are applicable
BODY 1ST DAY 2ND DAY
PART/SYSTEM

General Survey/
Mental Status

Integumentary

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 81 | Page
 Head & Face

Neck

Eyes

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 82 | Page
 Ears

Nose & Sinuses

Mouth & Throat

Lungs & Thorax

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 83 | Page
 Breast & Axillae

Heart

Abdomen

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 84 | Page
Gastrointestinal/
Nutrition

Musculoskeletal

Genitourinary

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 85 | Page
 Neurologic

BUBBLE-HEE ASSESSMENT

Instruction: Please write your focused assessment on the specific areas for
obstetric and gynecologic assessment. Be sure to categorize your findings into
IPPA (Inspection, Palpation, Percussion and Auscultation) format.

Assessment Area 1st Day 2nd Day

BREASTS
feeding method (if
breast feeding, state
frequency, duration),
bra, appearance,
palpation, nipples

UTERUS
fundus, diastasis recti
(vaginal birth only),
tenderness, C/S
dressing/ incision,
binder

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 86 | Page
 BLADDER
Bladder distension,
voiding adequately, or
Foley output, S/Sx of
infection

BOWEL
Bowel sounds, passing
flatus (C/S), BM

LOCHIA
Amount, color, odor,
clots

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 87 | Page
 EXTREMITY
Edema, pedal
pulses, capillary
refill, signs &
symptoms of DVT
(redness, pain,
increased skin
temperature,
unilateral swelling)

HOMAN’S SIGN
Degree of pain, calf
circumference,
color, capillary refill

EPISIOTOMY
Degree of
laceration,
perineum (REEDA –
Redness, Edema,

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 88 | Page
Ecchymosis, Drainage,
Approximation),
comfort measures,
Kegels;
HEMORRHOIDS –
pain, comfort
measures

EMOTIONAL
LABILITY

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 89 | Page
 DIAGNOSTIC, LABORATORY PROCEDURES & NURSING RESPONSIBILITIES

DIAGNOSTIC INDICATIONS & RESULTS/ NORMA

PROCEDURE PURPOSES
INTERPRETATION

DIAGNOSTIC, LABORATORY PROCEDURES & NURSING RESPONSIBILITIES

DIAGNOSTIC INDICATIONS & RESULTS/ NORMA

PROCEDURE PURPOSES

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 90 | Page
 INTERPRETATION

MEDICAL MANAGEMENT & NURSING RESPONSIBILITIES

Instructions: Fill – out the necessary information required on the tables.

I. Intravenous Fluid Therapy and Nursing Responsibilities
Intravenous Fluids General Description Indication or Purpose

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 91 | Page
II. Pharmacotherapy & Nursing Responsibilities

Drug Mechanism of Indications or Contraindications Side Effects A

Action Purpose
Generic Name:

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 92 | Page
Brand Name:

Classification:

Dose, Route &

Timing:

Drug Mechanism of Indications or Contraindications Side Effects A

Action Purpose
Generic Name:

Brand Name:

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 93 | Page
Classification:

Dose, Route &

Timing:

Drug Mechanism of Indications or Contraindications Side Effects A

Action Purpose
Generic Name:

Brand Name:

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 94 | Page
Classification:

Dose, Route &

Timing:

DIET & ACTIVITY MANAGEMENT & NURSING RESPONSIBILITIES

Type of Diet/Activity General Description Indication or Purposes Restricted Fo

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 95 | Page
CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 96 | Page
 MONITORING SHEET

Instructions: Fill – out the necessary data on vital signs monitoring and intake
and output sheet accordingly.

A. Vital Signs Monitoring

Shift: ______________

Date & Temp HR/PR RR BP O2 Sat

Time

B. Intake & Output Monitoring

Shift: ______________

Date & Intake Output

Time
IV IVT P Others Total Urine Stool Others Total
F T O

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 97 | Page
 TOTAL INTAKE TOTAL OUTPUT
TPR SHEET
(Please attach here)

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 98 | Page
CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 99 | Page
Instructions: Fill – out the table below with the appropriate nursing diagnosis and make your nursing care plan
utilizing the nursing process. NURSING PROCESS RECORD
Patient’s Name :
______________________________________________________________________
______________________________
Medical Diagnosis :
______________________________________________________________________
______________________________
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION (NOC) INTERVENTIONS
RATIONA
CLASSIFICATION (NIC)

Reference/s:
______________________________________________________________________
_____________________________________
NURSING PROCESS RECORD

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 100 | Page
Patient’s Name :
______________________________________________________________________
______________________________
Medical Diagnosis :
______________________________________________________________________
______________________________
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION (NOC) INTERVENTIONS
RATIONA
CLASSIFICATION (NIC)

Reference/s:
______________________________________________________________________
_____________________________________
NURSING PROCESS RECORD

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 101 | Page
Patient’s Name :
______________________________________________________________________
______________________________
Medical Diagnosis :
______________________________________________________________________
______________________________
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION (NOC) INTERVENTIONS
RATIONA
CLASSIFICATION (NIC)

Reference/s:
______________________________________________________________________
_____________________________________

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 102 | Page
 BREASTFEEDING OBSERVATION AID

Mother’s HRN : _________________________ Date _________________

Baby's HRN : _______________________________ Baby's age ____________

Signs that breastfeeding is going well: Signs of possible difficulty:

GENERAL
Mother: Mother:
⮚ Mother looks healthy ⮚ Mother looks ill or depressed
⮚ Mother relaxed and comfortable ⮚ Mother looks tense and uncomfortable
⮚ Signs of bonding between mother and baby ⮚ No mother/baby eye contact
Baby: Baby:
⮚ Baby looks healthy ⮚ Baby looks sleepy or ill
⮚ Baby calm and relaxed ⮚ Baby is restless or crying
⮚ Baby reaches or roots for breast if hungry ⮚ Baby does not reach or root

BREASTS
⮚ Breasts look healthy ⮚ Breasts look red, swollen, or sore
⮚ No pain or discomfort ⮚ Breast or nipple painful
⮚ Breast well supported with fingers away ⮚ Breasts held with fingers on areola
from nipple

BABY’S POSITION
⮚ Baby’s head and body in line ⮚ Baby’s neck and head twisted to feed
⮚ Baby held close to mother’s body ⮚ Baby not held close
⮚ Baby’s whole body supported ⮚ Baby supported by head and neck only
⮚ Baby approaches breast, nose to nipple ⮚ Baby approaches breast, lower lip/chin
to nipple
BABY’S ATTACHMENT
⮚ More areola seen above baby’s top lip ⮚ More areola seen below bottom lip
⮚ Baby’s mouth opens wide ⮚ Baby’s mouth not open wide
⮚ Lower lip turned outwards ⮚ Lips pointing forward or turned in
⮚ Baby’s chin touches breast ⮚ Baby’s chin not touching breast

SUCKLING
⮚ Slow, deep sucks with pauses ⮚ Rapid shallow sucks
⮚ Cheeks round when suckling ⮚ Cheeks pulled in when suckling
⮚ Baby releases breast when finished ⮚ Mother takes baby off the breast
⮚ Mother notices signs of oxytocin reflex ⮚ No signs of oxytocin reflex noticed

Notes:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Assessed by: _________________________________________

Student’s Signature over Printed Name

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 103 | Page
 Evidence – Based Nursing Research
(Reflection Paper)

Instructions: Search for a Research Article related to the case of your patient
and give your own reflection/insights.

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

CMU – CON: Clinical Workbook (OB - Gyne Nursing 2nd Edition) 104 | Page
 LEARNING FEEDBACK DIARY

Learnings Problems Encountered Actions Ta

Self

Peers

Patient’s
Area

Clinical
Instructor

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 105 | Page
 WEEK 4
Item Points
GOSO
Clinical Teaching Plan
Morse Fall Scale (Fall Assessment)
Maternal Health Assessment
Review of Systems
Bubble-Hee Assessment
Diagnostic, Laboratory Procedures and its Nursing
Responsibilities
Medical Management and its Nursing Responsibilities
vii. Intravenous Fluid Therapy & NR
viii. Pharmacotherapy & NR
Vital Signs Monitoring
TPR Sheet
Nursing Process Record
Breastfeeding Observation Aid
Evidence – Based Nursing Research (Reflection Paper)
Total

_____________________________________
Clinical Instructor

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 106 | Page
 GENERAL OBJECTIVE AND SPECIFIC OBJECTIVES (GOSO)

HRN : ___________________________________ Date: _______________

Hospital: __________________________________ Shift: _______________
Clinical Instructor: ___________________________ Area: _______________

GENERAL OBJECTIVE
1ST DAY 2ND DAY

SPECIFIC OBJECTIVES
1ST DAY 2ND DAY
Knowledge
7. 1.

8. 2.

Skills
5. 1.

6. 2.

Attitude
5. 1.

6. 2.

CLINICAL TEACHING PLAN

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 107 | Page
 Activities
Time 1ST Day 2ND Day

MORSE FALL SCALE

(Fall Assessment)

HRN: ______________________________ Age: _________ Date: __________

Instruction: Write the score that corresponds to the item being assessed on the
space provided.
Item Item Score Patient Score
19. History of falling (immediate or previous) No 0
Yes 25 ______
20. Secondary diagnosis (≥ 2 medical No 0
diagnosis in chart
Yes 15 ______
21. Ambulatory aid
⮚ None/bedrest/nurse assist 0
⮚ Crutches/cane/walker 15
⮚ furniture 30 ______

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 108 | Page
 22. Intravenous therapy/heparin lock No 0
Yes 20 ______
23. Gait
⮚ Normal/bedrest/wheelchair 0
⮚ Weak* 10
⮚ Impaired* 20 ______
24. Mental status
⮚ Oriented to own ability 0
⮚ Overestimates/forgets limitations 15 ______
TOTAL:
Interpretation: Tally the patient score and record.
<25 : Low risk
25-45 : Moderate risk
>45 : High risk

Note:
⮚ Weak Gait: Short steps (may shuffle), stooped but able to lift head while walking, may
seek support from furniture while walking, but with light touch (for reassurance).
⮚ Impaired gait: Short steps with shuffle; may have difficulty arising from chair; head down;
significantly impaired balance, requiring furniture, support person, or walking aid to walk.
⮚ Suggested scoring based on Morse JM, Black C, Oberle K, et al. A prospective study to
identify the fall-prone patient. Soc Sci Med 1989; 28(1):81-6. However, note that Morse
herself said that the appropriate cut-points to distinguish risk should be determined by
each institution based on the risk profile of its patients. For details, see Morse JM, Morse
RM, Tylko SJ. Development of a scale to identify the fall-prone patient. Can J
Aging 1989;8;366-7.

MATERNAL HEALTH ASSESSMENT

Instructions: Kindly fill-out the forms with the necessary information of the
patient. Write legibly and accurately.

I. PATIENT’S PROFILE

HRN : Age:

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 109 | Page
Birth Date : Sex:
Civil Status : Religion:
Address : Height:
Educational Attainment : Weight:
Occupation : Blood Type

Ethnic Group : Vital Signs

Date & Time of Admission: BP:
Attending Physician : RR:
Medical Diagnosis : PR:
Temp:
History of Allergy/ies :

Delivery Details :

Type of Delivery :
Medications (if given)

Date of Delivery : Time:

Episiotomy Type : Estimated blood loss:

Degree of Laceration: Type of Placenta:

II. OBSTETRIC HISTORY

LMP: _______________ G: ___ P: ___ (T: ___, P: ___, A: ___, L: ___)
EDC: _______________
AOG: _______________
Age of Menarche: ________________ Menstrual Cycle: _______ days
Duration : ________________

Gravid Place of Delivery Manner of Presentatio Complication

a Delivery n s
AOG

G1
G2
G3
G4
G5
G6
G7

III. OBSTETRIC RISK FACTORS

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 110 | Page
 [ ] Age (below 18 and above 35) [ ] Multiple Pregnancy

[ ] Ovarian Cyst [ ] Uterine Myoma [ ] Placenta previa

[ ] History of still birth [ ] History of 3 Miscarriages
[ ] History of pre-eclampsia/eclampsia [ ] Others: (please specify)
_____
___________________________________________________________
IV. ANTENATAL HISTORY

Variables 1ST TRIMESTER 2ND TRIMESTER 3RD TRIMESTER

Number of
Visits

Signs &
Symptoms of
Pregnancy

Diagnostic/s &
Laboratory
Test/s Result

Immunization/
s Given

Medication/s
Taken

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 111 | Page
V. FAMILY HEALTH HISTORY
[ ] Diabetes [ ] Asthma [ ] HPN [ ] Allergy
[ ] Bleeding disorder [ ] Mental Disorder [ ] Heart disease [ ] Epilepsy

[ ] Others: __________________________________________________

VI. PAST HEALTH HISTORY

Medical History: Hospitalized? [ ] Yes [ ] No
If Yes, when?____________________
Reason of hospitalization:
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________

Surgical History: [ ] Yes [ ] No

If Yes, when? ___________________
Reason and type of Surgery
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
VII. FAMILY PLANNING METHOD HISTORY
G. Natural Method
[ ] Calendar Method [ ] Abstinence [ ] Withdrawal
[ ] Cervical Mucus [ ] Basal Body Temperature
[ ] Standard Days Method [ ] Lactational Amenorrhea Method
[ ] Others: _____________________________________________

H. Artificial Method
[ ] IUD [ ] Pills [ ] Injectable (DEPO) [ ] Condom
[ ] Bilateral Tubal Ligation (BTL) [ ] Intradermal Implant
[ ] Others: _____________________________________________

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 112 | Page
 REVIEW OF SYSTEMS

Instructions: Kindly accomplish this matrix. Be sure to fill out with normal and
abnormal findings. Follow the IPPA or IAPP (Inspection, Percussion, Palpation
and Auscultation) format. Note: *Only for systems that are applicable
BODY 1ST DAY 2ND DAY
PART/SYSTEM

General Survey/
Mental Status

Integumentary

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 113 | Page
 Head & Face

Neck

Eyes

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 114 | Page
 Ears

Nose & Sinuses

Mouth & Throat

Lungs & Thorax

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 115 | Page
 Breast & Axillae

Heart

Abdomen

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 116 | Page
Gastrointestinal/
Nutrition

Musculoskeletal

Genitourinary

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 117 | Page
 Neurologic

BUBBLE-HEE ASSESSMENT

Instruction: Please write your focused assessment on the specific areas for
obstetric and gynecologic assessment. Be sure to categorize your findings into
IPPA (Inspection, Palpation, Percussion and Auscultation) format.

Assessment Area 1st Day 2nd Day

BREASTS
feeding method (if
breast feeding, state
frequency, duration),
bra, appearance,
palpation, nipples

UTERUS
fundus, diastasis recti
(vaginal birth only),
tenderness, C/S
dressing/ incision,
binder

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 118 | Page
 BLADDER
Bladder distension,
voiding adequately, or
Foley output, S/Sx of
infection

BOWEL
Bowel sounds, passing
flatus (C/S), BM

LOCHIA
Amount, color, odor,
clots

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 119 | Page
 EXTREMITY
Edema, pedal
pulses, capillary
refill, signs &
symptoms of DVT
(redness, pain,
increased skin
temperature,
unilateral swelling)

HOMAN’S SIGN
Degree of pain, calf
circumference,
color, capillary refill

EPISIOTOMY
Degree of
laceration,
perineum (REEDA –
Redness, Edema,

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 120 | Page
Ecchymosis, Drainage,
Approximation),
comfort measures,
Kegels;
HEMORRHOIDS –
pain, comfort
measures

EMOTIONAL
LABILITY

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 121 | Page
 DIAGNOSTICS & LABORATORY PROCEDURES & NURSING RESPONSIBILITIES

DIAGNOSTIC INDICATIONS & RESULTS/ NORMA

PROCEDURE PURPOSES
INTERPRETATION

DIAGNOSTIC, LABORATORY PROCEDURES & NURSING RESPONSIBILITIES

DIAGNOSTIC /LAB INDICATIONS & RESULTS/ NORMA

PROCEDURE PURPOSES

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 122 | Page
 INTERPRETATION

MEDICAL MANAGEMENT & NURSING RESPONSIBILITIES

Instructions: Fill – out the necessary information required on the tables.

I. Intravenous Fluid Therapy and Nursing Responsibilities
Intravenous Fluids General Description Indication or Purpose

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 123 | Page
II. Pharmacotherapy & Nursing Responsibilities

Drug Mechanism of Indications or Contraindications Side Effects A

Action Purpose
Generic Name:

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 124 | Page
Brand Name:

Classification:

Dose, Route &

Timing:

Drug Mechanism of Indications or Contraindications Side Effects A

Action Purpose
Generic Name:

Brand Name:

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 125 | Page
Classification:

Dose, Route &

Timing:

Drug Mechanism of Indications or Contraindications Side Effects A

Action Purpose
Generic Name:

Brand Name:

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 126 | Page
Classification:

Dose, Route &

Timing:

DIET & ACTIVITY MANAGEMENT & NURSING RESPONSIBILITIES

Type of Diet/Activity General Description Indication or Purposes Restricted Fo

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 127 | Page
CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 128 | Page
 MONITORING SHEET

Instructions: Fill – out the necessary data on vital signs monitoring and intake
and output sheet accordingly.

A. Vital Signs Monitoring

Shift: ______________

Date & Temp HR/PR RR BP O2 Sat

Time

B. Intake & Output Monitoring

Shift: ______________

Date & Intake Output

Time
IV IVT P Others Total Urine Stool Others Total
F T O

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 129 | Page
 TOTAL INTAKE TOTAL OUTPUT
TPR SHEET
(Please attach here)

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 130 | Page
CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 131 | Page
Instructions: Fill – out the table below with the appropriate nursing diagnosis and make your nursing care plan
utilizing the nursing process. NURSING PROCESS RECORD
Patient’s Name :
______________________________________________________________________
______________________________
Medical Diagnosis :
______________________________________________________________________
______________________________
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION (NOC) INTERVENTIONS
RATIONA
CLASSIFICATION (NIC)

Reference/s:
______________________________________________________________________
_____________________________________
NURSING PROCESS RECORD

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 132 | Page
Patient’s Name :
______________________________________________________________________
______________________________
Medical Diagnosis :
______________________________________________________________________
______________________________
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION (NOC) INTERVENTIONS
RATIONA
CLASSIFICATION (NIC)

Reference/s:
______________________________________________________________________
_____________________________________
NURSING PROCESS RECORD

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 133 | Page
Patient’s Name :
______________________________________________________________________
______________________________
Medical Diagnosis :
______________________________________________________________________
______________________________
NANDA Nursing Diagnosis:

NANDA Definition:
CUES/Defining NURSING OUTCOMES NURSING
Characteristics CLASSIFICATION (NOC) INTERVENTIONS
RATIONA
CLASSIFICATION (NIC)

Reference/s:
______________________________________________________________________
_____________________________________

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 134 | Page
 BREASTFEEDING OBSERVATION AID

Mother’s HRN : _________________________ Date _________________

Baby's HRN : _______________________________ Baby's age ____________

Signs that breastfeeding is going well: Signs of possible difficulty:

GENERAL
Mother: Mother:
⮚ Mother looks healthy ⮚ Mother looks ill or depressed
⮚ Mother relaxed and comfortable ⮚ Mother looks tense and uncomfortable
⮚ Signs of bonding between mother and baby ⮚ No mother/baby eye contact
Baby: Baby:
⮚ Baby looks healthy ⮚ Baby looks sleepy or ill
⮚ Baby calm and relaxed ⮚ Baby is restless or crying
⮚ Baby reaches or roots for breast if hungry ⮚ Baby does not reach or root

BREASTS
⮚ Breasts look healthy ⮚ Breasts look red, swollen, or sore
⮚ No pain or discomfort ⮚ Breast or nipple painful
⮚ Breast well supported with fingers away ⮚ Breasts held with fingers on areola
from nipple

BABY’S POSITION
⮚ Baby’s head and body in line ⮚ Baby’s neck and head twisted to feed
⮚ Baby held close to mother’s body ⮚ Baby not held close
⮚ Baby’s whole body supported ⮚ Baby supported by head and neck only
⮚ Baby approaches breast, nose to nipple ⮚ Baby approaches breast, lower lip/chin
to nipple
BABY’S ATTACHMENT
⮚ More areola seen above baby’s top lip ⮚ More areola seen below bottom lip
⮚ Baby’s mouth opens wide ⮚ Baby’s mouth not open wide
⮚ Lower lip turned outwards ⮚ Lips pointing forward or turned in
⮚ Baby’s chin touches breast ⮚ Baby’s chin not touching breast

SUCKLING
⮚ Slow, deep sucks with pauses ⮚ Rapid shallow sucks
⮚ Cheeks round when suckling ⮚ Cheeks pulled in when suckling
⮚ Baby releases breast when finished ⮚ Mother takes baby off the breast
⮚ Mother notices signs of oxytocin reflex ⮚ No signs of oxytocin reflex noticed

Notes:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Assessed by: _________________________________________

Student’s Signature over Printed Name

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 135 | Page
 Evidence – Based Nursing Research
(Reflection Paper)

Instructions: Search for a Research Article related to the case of your patient
and give your own reflection/insights.

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 136 | Page
 LEARNING FEEDBACK DIARY

Learnings Problems Encountered Actions Ta

Self

Peers

Patient’s
Area

Clinical
Instructor

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 137 | Page
 APPENDICES

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 138 | Page
Appendix A

RUBRIC FOR REFLECTIVE JOURNAL

POINTS DESCRIPTION
Content
Excellent to very good: knowledgeable, substantive, thorough;
include appropriate examples; quotations are well-chosen to
(10 pts)
support the argument, well integrated and presented correctly,
good analysis and synthesis of the topic. Good use of
comparison and contrast, critical inquiry and interpretation,
interpretation is imaginative and valued.
Good to average: some knowledge of the subject; adequate
range of analysis and synthesis; limited use of examples;
(8 pts)
mostly relevant to the topic but lacks detail in critical
interpretation; readings/ articles adequately support the
argument or topic but may be too long or too short. Articles or
readings shows some originality.
(6 pts) Fair to poor: limited knowledge of the subject, minimal
substance, analysis and synthesis, inadequate use of
quotations, articles or readings. Interpretation is predictable
and or unfocused.
(4 pts) Very poor: shows little or no knowledge of the subject; lacking
analysis or synthesis of the materials and lacking good
examples; inadequate quantity; not relevant, or not enough to
rate. Interpretation is copied.
Organization and Format
Excellent to very good: clear statement of ideas, clear
organization of thoughts (beginning, middle, and end) and
smooth transitions; introduction leads reader into topic;
(10 pts) conclusion effectively summarizes main points; bibliographical
material length, spacing, fonts, margin, numbered pages all
carefully adhered to.
Good to average: main ideas clear but loosely organized or
connected; little pertinent to the topic. Sequencing logical and
(8 pts)
incomplete, bibliographical material and formatting adequate.
Fair to poor: ideas not well connected; little too general; poor
organization of thoughts, logical sequencing and development
(6 pts)
lacking; formatting inadequate.
Very poor: ideas not communicated; no title; organization,
sequencing and transitions lacking, or not enough to rate,
(4 pts)
formatting lacking.
Grammar, Vocabulary and Fluency
Excellent to very good: fluent expression; accurate use of
grammar. Complex range of vocabulary; accurate word or
(10 pts)
idiom choice; mastery of construction of sentences.
Good to average: adequate fluency; significant mistakes in the

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 139 | Page
 (8 pts) usage of grammar, some problems in the construction of
sentences; some spelling errors.
Fair to poor: low fluency; significant mistakes in the
construction of sentences, frequent grammar and spelling
(6pts)
errors; lack of accuracy interferes with meaning.

Very poor: lacks fluency, no mastery of simple sentence

constructions, text dominated by errors, does not communicate
(4 pts)
meaning, not enough to rate.

Appendix B.

COMMONLY USED ABBREVIATIONS IN OB – Gyne

AB abortion
MAB missed abortion
SAB spontaneous abortion
TAB therapeutic abortion
EAB elective abortion
ACOG American College of Obstetricians and Gynecologists
AFP Alpha Fetoprotein
MSAFP - maternal serum alpha-fetoprotein
AGUS atypical glandular cells of unknown significance
AMA advanced maternal age
AFI amniotic fluid index
APGO Association of Professors of Gynecology & Obstetrics
AROM artificial rupture of membranes
ASCUS atypical squamous cells of unknown significance
BBOW bulging bag of water
BBT basal body temperature
BMD bone mineral density
BPD biparietal diameter
BPP biophysical profile
BSO bilateral salpingo-oophorectomy
BTBV beat-to-beat variability
BTL bilateral tubal ligation
CIN cervical intraepithelial neoplasia
CPD cephalopelvic disproportion
CRL crown rump length
CST contraction stress test
CT chlamydia trachomatous
CVS chorionic villi sampling
D&C dilatation & curettage
D&E dilatation & evacuation
DIC disseminating intravascular coagulopathy
DI/DI dichorionic/diamniotic twins
EDC/EDD estimated date of confinement/estimated date of delivery
EFM electronic fetal monitoring
EFW estimated fetal weight
EGA estimated gestational age
EMB endometrial biopsy
ERT estrogen replacement therapy

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 140 | Page
FAVD forceps assisted vaginal delivery
FHR/FHT fetal heart rate/fetal heart tracing or tone
FL femur length
FLM fetal lung maturity
FM fetal movement
FSE fetal scalp electrode
FSH follicle stimulating hormone
FTP failure to progress
GBS/GBBS group B beta streptococcus
GC gonorrhea
GDM gestational diabetes mellitus

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 141 | Page
GIFT gamete intra-fallopian tube transfer
GnRH gonadotropin releasing hormone
G_P_ gravida, para (TPAL- term, preterm, abortion, living children)
GTD gestational trophoblastic disease
HCG human chorionic gonadotropin
BHCG - beta human chorionic gonadotropin (usually serum)
UHCG - urinary human chorionic gonadotropin
HELLP hemolysis, elevated liver enzymes, low platelets
HGSIL high-grade squamous intraepithelial lesion
HPL human placental lactogen
HPV human papilloma virus
HRT hormone replacement therapy
HSG hysterosalpingogram
HSV herpes simplex virus
I&D incision & drainage
ICSI intracytoplasmic sperm injection
IUD intrauterine device
IUFD intrauterine fetal death
IUGR intrauterine growth retardation
IUI intrauterine insemination
IUP intrauterine pregnancy
IUPC intrauterine pregnancy pressure catheter
IVF in vitro fertilization
LCP long, closed, posterior
LEEP/LOOP loop electrical excision procedure
LGA large for gestational age
LGSIL low grade squamous intraepithelial lesion
LH luteinizing hormone
LMP/LNMP last menstrual period/last normal menstrual period
LOA/LOT/LOP left occiput anterior/left occiput transverse/left occiput
posterior
LTC long, thick, closed
LTCS/LVCS low transverse C- section/low vertical C-section MFM
maternal fetal medicine
MVU Montevideo units
NST non-stress test
NSVD normal spontaneous vaginal delivery
NT nuchal translucency
NTD neural tube defect
OCP oral contraceptive pills
OT occiput transverse
PCO/PCOD polycystic ovarian disease
PCT post-coital testing
PID pelvic inflammatory disease
PIH pregnancy induced hypertension
PMB postmenopausal bleeding
POC products of conception
POD/PPD post-operative day/postpartum day
PPH postpartum hemorrhage
PPROM preterm premature rupture of membranes
PROM premature rupture of membranes
PTL preterm labor
PUBS percutaneous umbilical blood sampling
PUPPPS pruritic urticarial papules and plaques of pregnancy
ROA/ROT/ROP right occiput anterior/right occiput transverse/right occiput

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 142 | Page
 posterior
ROM rupture of membranes
SBE self-breast exam
SGA small for gestational age
SROM spontaneous rupture of membranes
SSE sterile speculum exam
STD/STI sexually transmitted disease/sexually
transmitted infection SVE sterile vaginal exam
TAH total abdominal hysterectomy
TOA tubo-ovarian abscess
TOL trial of labor
TRIPLE TEST MSAFP/HCG/Estriol
TVH total vaginal hysterectomy
US ultrasound
VAVD vacuum-assisted vaginal delivery
VB vaginal bleeding
VBAC vaginal birth after C-section
VAIN vaginal intraepithelial neoplasia
VIN vulvar intraepithelial neoplasia

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 143 | Page
Appendix C.

COMMONLY USED ABBREVIATIONS IN NURSING

SYMBOL MEANING
a: Before
@: at
A&P: anterior and posterior
aa: of each
abd: abdomen
ABGs: arterial blood gases
ac: before meals
American Diabetes Association or American Dietetic
ADA: Association
ad lib: as desired or as freely as desired
ADH: antidiuretic hormone
ADL: activities of daily living
AF: atrial fibrillation
AFB: acid-fast bacillus
Ag: silver or antigen
American Hospital Association or American Heart
AHA: Association
AHCD: advanced health care directive
AIDS: acquired immune deficiency syndrome
AKA: above the knee amputation
acute lymphocytic leukemia or acute lymphoblastic
ALL: leukemia
ALOC: altered level of consciousness
ALS: amyotrophic lateral sclerosis
a.m.a.: against medical advice
A.M.A.: American Medical Association
AMB or amb: ambulatory
acute myocardial infarction or anterior myocardial
AMI: infarction
amp: ampule
antinuclear antibody test or American Nurses
ANA: Association
AP: apical pulse or anterior and posterior
acute respiratory distress syndrome or adult respiratory
ARDS: distress syndrome
AS: aortic stenosis
ASA: aspirin or acetyl salicylic acid
ASD: atrial septal defect
ASHD: arteriosclerotic heart disease
AST: aspartate aminotransferase
AV: atrio-ventricular or arterio-venous
ax: axillary
Ba: barium
BE: barium enema
bid: two times a day
BKA: below the knee amputation
BM: bowel movement
BMR: basal metabolic rate
BP: blood pressure
BPH: benign prostatic hypertrophy
BR: bedrest
BRP: bathroom privileges

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 144 | Page
 BSA: body surface area
BSC: bedside commode
BSE: breast self-examination
BSI: body substance isolation
BSO: bilateral salpingo-oophorectomy
BUN: blood urea nitrogen
bx: biopsy
c: with
C: Centigrade
C&S: culture and sensitivity
++ calcium
Ca :
CA: cancer or carcinoma
CABG: coronary artery bypass graft
CAD: coronary artery disease
cap: capsule
CAPD: continuous ambulatory peritoneal dialysis
CAT: computed axial tomography
cath: catheter or catheterize
CBC: complete blood count
CBI: continuous bladder irrigation
CBR: complete bedrest
cc: cubic centimeter
CCU: Coronary Care Unit or Critical Care Unit
CC: chief complaint
CDC: Centers for Disease Control
CDE: Certified Diabetes Educator
CEA: carcinoembryonic antigen
cg: centigram
CHF: congestive heart failure
CHO: carbohydrate
CKD chronic kidney disease
Cl :
- chloride or chlorine
cm: centimeter
CMS: circulation, movement, sensation or color, movement,
sensation
CN: cranial nerve
CNS: central nervous system
c/o: complains of or complaint of
CO: cardiac output or carbon monoxide
CO2: carbon dioxide
COPD: chronic obstructive pulmonary disease
CPK: creatinine phosphokinase
CPM: continuous passive motion
CPR: cardiopulmonary resuscitation
CRT: capillary refill time
CSF: cerebrospinal fluid
CT: computed tomography or chest tube
CVA: cerebrovascular accident or costovertebral angle
CVP: central venous pressure
CXR: chest x-ray
dc; D/C: discontinue
D&C: dilation and curettage
DIC: disseminated intravascular coagulation
diff: differential or differential blood count
dil: dilute or diluent
DKA: diabetic ketoacidosis

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 145 | Page
 dl: deciliter
DM: diabetes mellitus or diastolic murmur
DNR: do not resuscitate
DOE: dyspnea on exertion
DSD: dry sterile dressing
DTR: deep tendon reflex or deep tendon reflexes
DVT: deep vein thrombosis
DW: daily weight
D5W: 5% dextrose in water
dx; DX: diagnosis
EC: enteric-coated
ECF: extracellular fluid
ECG; EKG: electrocardiogram
ECT: electroconvulsive therapy
EDB: estimated date of birth
EDD: estimated date of delivery
EEG: electroencephalogram
EGD: esophagogastroduodenoscopy
elix: elixir
EMG: electromyogram
ENT: ear, nose and throat
EOM: extra-ocular movements
ER: extended release or Emergency Room
ESR: erythrocyte sedimentation rate
ESRD: end-stage renal disease
ESRF: end-stage renal failure
ET: enterostomal therapist
ETOH: ethyl alcohol or ethanol
F: Fahrenheit
Fe: iron
FeSO4: iron sulfate
FHR: fetal heart rate
FSBS: fingerstick blood sugar
f/u: follow up
FUO: fever of unknown origin
fx; Fx: fracture or fractional urine test
g; gm; Gm: gram
GERD: gastroesophageal reflux disease
GI: gastrointestinal
gr: grain
grav I, II, III, etc: gravida (pregnancy) 1, 2, 3, etc.
GSW: gunshot wound
gtt: drop or drops
GTT: glucose tolerance test
GU: genitourinary
GYN; Gyn: gynecological
h: hour
+ hydrogen ion
H :
H/A: headache
H/H: hemoglobin and hematocrit
H&P: history and physical examination
HAV: hepatitis A virus
Hb; Hgb: hemoglobin
HBAg: hepatitis B antigen
HBV: hepatitis B virus
HCO3 :
- bicarbonate

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 146 | Page
 Hct; HCT: hematocrit
HCV: hepatitis C virus
HEENT head, eyes, ears, nose and throat
HD: hemodialysis
Hg: mercury
HHNS: hyperglycemic hyperosmolar nonketotic syndrome
HIPAA: Health Insurance Portability and Accountability Act
HIV: human immunodeficiency virus
h/o: history of
H2O: water
HOB: head of bed
HOH: hard of hearing
HR: heart rate
hs: at bedtime
HTN: hypertension
I&D: incision and drainage
I&O: intake and output
ICD: implantable cardiac defibrillator
ICF: intracellular fluid
ICP: intracranial pressure
ICU: intensive care unit
ID: intradermal
Ig: immunoglobulin
IHI: Institute for healthcare improvement
IM: intramuscular
INR: International Normalized Ratio
IOM: Institute of Medicine
IOP: intraocular pressure
IPPB: intermittent positive pressure breathing
IS: incentive spirometry
IV: intravenous
IVDA: intravenous drug abuse
IVP: intravenous push or intravenous pyelogram
JVD: jugular vein distention or jugular venous distention
+
K : potassium
Kg: kilogram
KUB: kidney, ureters, bladder
KVO; kvo: keep vein open
L; l: liter
LA: left atrium or left atrial
LBBB: left bundle branch block
LDH: lactic dehydrogenase
LLL: left lower lobe
LLQ: left lower quadrant
LMP: last menstrual period
LOC: level of consciousness
LP: lumbar puncture
LUL: left upper lobe
LUQ: left upper quadrant
LV: left ventricle or left ventricular
LVH: left ventricular hypertrophy
lytes: electrolytes
m: meter
m; min: minim
MAP: mean arterial pressure
M.A.R.: Medication Administration Record

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 147 | Page
 mcg: microgram
MCV: mean corpuscular volume or mean cell volume
MDI: metered dose inhaler
meq: milliequivalent
met(s): metastasis or metastases
mg: milligram
Mg: magnesium
MI: myocardial infarction
Mobile Intensive Care Unit or Medical Intensive Care
MICU: Unit
ml: milliliter
mm: millimeter
MR: mitral regurgitation
MRI: magnetic resonance imaging
MRSA: methicillin resistant staph aureus
MS: multiple sclerosis or mitral stenosis
MVA: motor vehicle accident
MVC: motor vehicle crash
MW: molecular weight
N: nitrogen
Na: sodium
NaCl: sodium chloride
neg: negative
NG: nasogastric
NICU: Neonatal Intensive Care Unit
NIH: National Institutes of Health
NKA: no known allergies
NKDA: no known drug allergies
NMR: nuclear magnetic resonance
noc: night
NPO: nothing by mouth
NPSG National Patient Safety Goals
NS: normal saline
NSAIDS: nonsteroidal anti-inflammatory drugs
NSR: normal sinus rhythm
NWB: non weight bearing or no weight bearing
O&P: ova and parasites
O2: oxygen
OOB: out of bed
OR: Operating Room
ORIF: open reduction and internal fixation
O.T.: Occupational Therapy or Occupational Therapist
OTC: over the counter
p: after
P: pulse
PA: pulmonary artery
PACU: Postanesthesia Care Unit
pc: after meals
PCA: patient-controlled analgesia
PCN: penicillin
PE: pulmonary embolus or physical examination
PEEP: positive end expiratory pressure
PEG: percutaneous endoscopic gastrostomy
per: through or by way of
PERRLA: pupils equal, round, reactive to light and accommodation
PHI Protected Health Information
PICC: peripherally inserted central catheter

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 148 | Page
 PID: pelvic inflammatory disease
PMH: past medical history
point of maximum impulse or point of maximal
PMI: impulse
PNA: pneumonia
PND: paroxysmal nocturnal dyspnea
po: by mouth
P.O.D.: post-operative day
pos: positive
postop: postoperative or after surgery
PPD: purified protein derivative
ppd: packs per day
PPN: partial parenteral nutrition
preop: preoperative or before surgery
PRN: as needed
PSA: prostate specific antigen
pt; Pt: patient
Physical Therapy or Physical Therapist or prothrombin
PT: time
PTCA: percutaneous transluminal coronary angioplasty
PTT: partial thromboplastin time
PUD: peptic ulcer disease
PVC: premature ventricular contraction
PVD: peripheral vascular disease
q: every or each
qid: four times a day
qs: quantity sufficient
QSEN: Quality and Safety Education for Nurses
R: respirations
RA: rheumatoid arthritis or right atrium
RBC: red blood cell
RLL: right lower lobe
RLQ: right lower quadrant
RML: right middle lobe
R/O: rule out
ROM: range of motion or rupture of membranes
ROS: review of systems
RRR: regular rate and rhythm
r/t: related to
RT: Respiratory Therapist or Respiratory Therapy
RUL: right upper lobe
RUQ: right upper quadrant
RV: right ventricle or right ventricular
Rx: treatment or take
s: without
SBO: small bowel obstruction
SCD: sequential compression device
SGOT: serum glutamic oxaloacetic transaminase
SICU Surgical Intensive Care Unit
SL; sl: Sublingual
SLE: systemic lupus erythematosus
SNF: Skilled Nursing Facility
S.O.A.P.: subjective, objective, assessment, plan
SOB: shortness of breath
sol: solution
s/p: status post
SR: sustained release

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 149 | Page
 s/s: signs and symptoms
STAT: immediately
STD: sexually transmitted disease
Subcut: subcutaneous
supp: suppository
susp: suspension
SVT: supraventricular tachycardia
sx: symptoms or signs
T: temperature
T&C: type and cross
TAH: total abdominal hysterectomy
TB: tuberculosis
TCDB: turn, cough, deep breathe
TEA: thromboendarterectomy
THR: total hip replacement
TIA: transient ischemic attack
TJC: The Joint Commission
tid: three times a day
TKO: to keep open
TKR: total knee replacement
TPN: total parenteral nutrition
TPR: temperature, pulse, respirations
TSH: thyroid stimulating hormone
TURP: transurethral resection of the prostate
UA: urinalysis
up ad lib: up as desired or up as freely as desired
URI: upper respiratory infection
US: ultrasound
UTI: urinary tract infection
V.A.C.: vacuum assisted closure
VS: vital signs
VTBI: volume to be infused
W/A: while awake
WBC: white blood count or white blood cell
WC: wheelchair
WNL: within normal limits
wt: weight

CMU – CON: Clinical Workbook (OB – Gyne Nursing 2nd Edition) 150 | Page
Appendix D.
MEDICAL PREFIXES

PREFIX MEANING EXAMPLE

a-, an-, in- Without, Amenorrhea- without a monthly flow
negative
ab- From, away Abnormal- away from normal
from
ad-, ac-, as-, at- To, toward Adduct- carry toward
aniso- Unequal Anisocytosis- abnormal condition of
unequal cells
ante-, pre- Before Anterior-front; prenatal- before birth
anti-, ant, ob- Against Antipyretic- agent used against fever
bi- to Bilateral- two sides
bio- life Biology- study of life
brachy short Brachydactylism- short fingers and
toes
brady slow Bradycardia- slow heart rate
cent- hundred Centimeter- 1/100 of a meter
circum- Around Circumcision- to cut around
co-, com, con- With, together Congenital- born with
contra- Against Contraindicated- against indication
de- Away from Dehydrated- loss of water
dextro- right Dextrocardia- heat displaced to right
dia- through Diarrhea- flow through
dis- apart Dissect- to cut apart
dys- bad, difficult Dyspnea- difficult breathing
e-, ex- out, out from Excise- to cut out
ect-, exo-, extra- outside Extracorporeal- outside the body
en- in, on Encapsulated- in a capsule
end- within Endoscopy- visualization within
epi- upon Epidermis- upon the skin
eu- good Euphonic- good sound
hemi-, semi- half Hemigastrectomy- surgical removal of
half of the stomach
hyper- over, above Hyperkinetic- overactive
hypo- under, below Hypoglossal- under the toungue
immune- free, exempt Immunity-exempt from the effects of

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 specific disease-causing agent
infra- beneath Inframammary- beneath the breast
inter- between Intercellular- between the cells
intra- within Intracranial- within the cranium
kilo thousand Kilogram- 1,000 grams
lyso- dissolution, Lysosome- organelle that degrades
disintegration worn cell parts
macro- large Macrocyte- large cells
mal- bad Malnutrition- bad nourishment
mes- middle Mesentery- middle of intestine
meta- after, beyond Metacarpals- beyond the carpals
(wrist)
micro- small Microcephalic- having a small head
milli- one-thousandth Milliliter- 1/1000 of a liter
multi- many Multipara- one who has many children
neo- new Neoplasm- new growth
olig- scanty, few Oliguria- scanty amount of urine
onc- tumor Oncology- study of tumors
per- through Percutaneous- through the skin
peri- around Peritonsillar- around the tonsil
pleur- rib, side Pleural membranes, serous
membranes that encloses the lungs
poly- much, many Polycystic- many cysts
post- after Postmortem- after death
pre- before Prenatal- before birth
presby- old Presbyopia- old vision
primi- first Primigravida- first pregnancy
pro- before Prognosis- foreknowledge, predict
outcome
re- back , again Regenerate- produce, develop again
retr- behind Retrosternal- behind the sternum
sub- under Sublingual- below the tounge
super-, supra- above Superior- above
syn-, sym- with, together Synergism- working together
tachy- fast Tachyphasia- fast speech

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Appendix E.
MEDICAL SUFFIXES

SUFFIX MEANING EXAMPLE

-algia Pain Dentalgia- pain in the tooth
-atresia Without an Procatresia – rectum without and
opening opening
-cele Hernia Omphalocele- umbilical hernia
-centesis Puncture to Arthrocentesis- puncture to aspirate
aspirate fluid from a joint
-cept Take, receive Receptor- something that receives
again
-cide Kill Bactericidal- able to kill bacteria

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-cis Cut Circumcision- cutting around
-cyte Ell Erythrocyte- red cell
-denia Pain Cephalodenia- pain in the head
-desis Fusion Arthrodesis- fusion of a joint
-ectasia Expansion Corectasis- expanding/ dilating pupil
-ectomy Cut out, excise Nephrectomy- surgically remove
kidney
-edema Swelling Cephaledema- swelling of head
-emesis Vomiting Hyperemesis- excessive vomiting
-emia Blood Hyperglycemia- elevated blood sugar
-ognosis Knowledge Diagnosis- knowledge through
examination (determining cause of
disease)
-gram Record Myelogram- Xray of the spinal cord
-graphy Making a record Angiography-making a record of the
vessels
-iasis Condition Cholelithiasis- condition of gallstones
-ist One who Optometrist- one who measures vision
-it is Inflammation Adenitis- inflammation of a gland
-lepsy Seizures Narcolepsy- seizures of numbness
-logist One who Ophthalmologist- one specializing in
specializes eyes
-logy Study of Biology- study of life
-lysis, -lytic, -lyze Break down, Tenolysis- distruction of tendons
dissolved
-lyt Dissolvable Electrolyte- substance
-malacia Abnormal Osteomalacia- abnormal softening of
softening bone
-mania Madness Pyromania- irresistible urge to set fire
-megaly Enlargement Splenomegaly- enlargement of the
spleen
-meter Measure Thermometer- instrument to measure
temperature
-oid Resembling Mucoid- resembling mucus
-oma Tumor Neurma- nerve tumor
-opia Vision Amblyopia- dim vision
-osis Abnormal Nephrosis- abnormal condition of
condition kidney
-osme Smell Anosmia- inability to smell

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-ostomy Create an Colostomy- create an opening in the
opening colon
-otia Ear Macrotia- large ear
-pathy Disease Encephalopathy- disease of the brain
-penia Deficiency, poor Leukocytopenia- deficiency of white
cells
-pepsia Digestion Dyspepsia- bad digestion
-pexy Surgical fixation Nephropexy- surgical fixation of kidney
-phasia Speak, say Aphasia- inability to speak
-philia Love, attraction chromophillic
-phobia Abnormal fear Agoraphobia- abnormal fear of crowds
-plasia Formation Hyperplasia- excessive formation
-plasm Substance Protoplasm- original substance
-plasty Make, shape Rhinoplasty- to shape the nose
-plegia Paralysis Hemiplegia- paralysis of one half of
body
-pnea Breath Tachypnea- fast breathing
-ptosis Prolapse, Hysteroptosis- prolapse of uterus
dropping
-rrhagia Burst forth Metorrhagia- hemorrhage from uterus
-rrhaphy Suture, sew Herniorrhaphy- suture of hernia
-rrhea Flow, discharge Otorrhea- discharge from ear
-rrhexis Rupture Splenorrhexis- rupture of the spleen
-scope Instrument for Otoscope- instrument to look in ears
viewing
-scopy Visualization Laryngoscopy- visualization of larynx
-some, -soma Body Lysosome- body that lyses/ dissolves
-spasm Twitching Blepharospasm- twitching of eyelids
-stasis Stop, control Hemostasis- control bleeding
-therapy Treatment Hydeotherapy- treatment with water
-tome Instrument to Osteotome- instrument to cut bone
cut
-tomy To cut Laparotomy- to cut into the abdomen
-tripsy Crushing Nephrolithotripsy- crushing stone in
kidney
-trophy, -trophic, development Hypertrophy- over deveolpment
-trophin
-uria Urine Hematuria-blood in the urine

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Appendix F.
MEDICAL ROOTS

ROOTS MEANING EXAMPLE

Acr- Extremity Acromegaly- enlarged extremities
Acrophobia- abnormal fear for heights
Aden- Gland Adenopathy- disease of a gland
Aer- Air Aerophagia- swallowing air
Angi- Vessel Angioma- tumor of a vessel
Arthr- Joint Arthralgia- pain in the joint
Blast- Bud, growing Neuroblast- growing nerve cell
thing
Blephar- Eyelid Blepharoptosis- drooping of eyelid
Brachi- Arm Brachial- pertaining to the arm
Bronch- Windpipe Bronchus- a branch of the trachea
(windpipe)
Carcin- Cancer Adenocarcinoma- cancerous tumor of
a gland
Cardi- Heart Myocarditis- inflammation of heart
muscle
Carp- Wrist Flexor carpi- muscle to bend wrist
Caud- Tail Caudal- pertaining to tail
Celio- Abdomen Celiotomy- incision of the stomach
Cephal- Head Cephalodynia- pain in the head
Cervic- Neck Cervicitis- inflammation of the neck of

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 the uterus
Cheil- Lip Cheiloplasty- shaping the lip
Cheir, Chir Hand Chiromegaly- large hands
Chol- Bite, gall Cholecystectomy- surgical removal of
the gallbladder
Chondr- Cartilage Chondro/ malacia- softening of the
cartilage
Chrom- Color Polychromatic- having many colors
Chron- Time Synchronous- occurring at the same
time
Col- Colon Megacolon- enlarged colon
Colp- Vagina Colporrhaphy- suture of vagina
Cost- Rib Intercostal- between ribs
Crani- Skull Craniotomy-incision into the skull
Cry- Cold Cryophilic- cold loving
Crypt- Hidden Cryptorchidism- hidden (undescended)
testicle
Cutan-, cut- Skin Subcutaneous- below the skin
Cyan- Blue Acrocyanosis- abnormal condition of
blueness of extremities
Cyst- Bladder Cystocele- bladder hernia
Cyt- Cell Thrombocyte- clotting cell (platelet)
Dacry- Tear Dacryorrhea- flow of tears
Dent-, odont- Tooth Periodontal- around the teeth
Dentalgia- toothache
Derm-, dermat- Skin Intradermal- within the skin
Dextr- Right Dextrocardia- heart displaced to the
right
Dips- Thirst Polydipsia- excessive thirst
Dors- Back Dorsal- pertaining to the back
Duct- Carry Oviduct- tube to carry ova (eggs)
Encephal- Brain Encephalocele- hernia of the brain
Enter- Intestine Gastroenteritis- inflammation of
stomach and intestines
Erg- Work Energy- working with
Erthyr- Red Erthyrocytopenia- deficiency of red
blood cells
Esthe- Sensation Anesthetic- agent to eliminate
sensation

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Esthen- Weakness Myasthenia- muscle weakness
Febr- Fever Afebrile- without fever
Gastr- Stomach Gastroscopy- visualization of the
stomach
Gen- Produce Pathogenic- agent that produces
diseases
Ginggiv- Gums Gingivectomy- removal of gums
Gloss- Tongue Hypoglossal- under the tongue
Glyc-, gluc- Sugar Hypoglycemia- low blood sugar
Gnath- Saw Micrognathism- small jaw
Grav- Heavy Secundigravida- second pregnancy
Gynec- Female Gynecology- study of female
conditions
Hem-, hemat- Blood Hematemesis-vomiting blood
Hepat- Liver Hepatomegaly- enlarged liver
Heter- Different Heterogeneous- different origins
Hidr- Perspiration Hidrorrhea- flow of perspiration
Troph- Turn Ectropion- turned out
Ur- Urine Uremia- urine constituents in the blood
Vas- Vessel Vasoconstriction- narrowing of a vessel
Vert- Turn Retroverted- turned backward
Vasic- Bladder Vasicocele- hernia of the bladder
Viscer- Internal organs Evisceration- process of viscera
protruding from abdominal wall
Vitra- Life Vital- necessary for life

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