UNIVERSITY HOSPITAL AND CLINICAL PROGRAMS PROFESSIONAL NURSING ORGANIZATION 

POLICY STANDARDS

ADDENDUM:                   I.1d EFFECTIVE:                   12/98
REVISION:                        3/08
APPROVAL:                      4/08

SUBJECT: OBSTETRICAL BIOPHYSICAL ASSESSMENT STANDARDS

Standards Based Documentation requires standardized criteria against which all assessments are compared. These standards outline what is consistent with a normal or expected biophysical finding. If a patient meets the standard a check, "Ö ", is placed in the appropriate box. If a patient’s assessment varies from the norm, the deviation is noted with an asterisk, "* " and documented with a Focus Note. http://www.uams.edu/nursingmanual/Policy-addenda/addendum-I1.htm

1. Neurological Assessment

1. Alert and oriented to person place and time.  
2. Pupils equal and reactive to light.  
3. Symmetry of strength of all extremities.  
4. Without parasthesia.  
5. Speech clear.  
6. Swallowing without coughing or choking on liquids or solids.  
7. Reflexes 1-2+ 

2. Cardiovascular Assessment

1. Peripheral pulses palpable.
2. Regular rhythm and rate.
3. Neck veins flat at 45 degrees of head of bed elevation.
4. Extremities without pitting edema.  
5. Calf tenderness, warmth, redness absent.
6. Capillary refill <3 seconds

3. Respiratory Assessment

1. Respirations unlabored/regular at rest.
2. Sputum (if present) clear
3.  Breath sounds are clear.
4. Nailbeds & mucous membranes pink.

1. Gastrointestinal Assessment

1. Abdomen soft.
2. Bowel sounds active.
3. No pain with palpation.
4. Tolerates prescribed diet without nausea or vomiting.
5. Bowel movements regular with normal consistency and color.

5. Genitourinary Assessment

1. Able to void without difficulty.
2. Bladder not distended after voiding.
3. Clear yellow urine.
4. Voided within 6 hrs. post delivery/post catheterization.

6. Psychosocial Assessment

1. Appropriate to current situation.
2. Positive bonding.

G.     Integumentary Assessment

1. Skin color is within patient's norm.
2. Skin is warm, dry, and intact.
3. Turgor is elastic.
4. Mucous membranes are moist.
5. Skin breakdown absent.
6. Episiotomy/laceration repair or surgical incision is intact
7. Perineum/labia with none to mild edema and/or none to slight bruising

8. Musculoskeletal Assessment

1. No joint swelling and tenderness.
2.  Equal and smooth movement of joints is noted.
3. No muscle weakness.
4. Surrounding tissue is free of erythema or pain.
5. No visible deformity.

1

 I. Fundus (PP only)

1. Firm upon palpation.
2. Midline position.
3. No appreciable tenderness.

11. Lochia ( PP only)

1. No foul odor.
2. Scant to small amount without clots.
3. Lochia color consistent with days post delivery

12. Breast (PP only)

1. None to minimal engorgement.
2. If breastfeeding, absence of inverted and/or flat nipple.
3. Without nipple redness or breakdown

13. OB

1. Greater than 37 completed weeks gestation
2. FHR 110-160 with a regular rhythm
3. Membranes intact in a non-laboring patient
4. Positive fetal movement per patient report
5. Vaginal discharge without foul odor
6. Without signs of worsening pre-eclampsia

14. CVL/IV

1. Site without redness, tenderness or edema
2. Flushes without difficulty
3. Dressing clean, dry and intact

15. Incisional Dressing

1. Clean, dry and intact