INTRANATAL ASSESSMENT KEMPEGOWDA COLLEGE OF NURSING, V.V.

PURAM, BLORE-04 INTRODUCTION

BASELINE DATA Name Age Ip.no Education Occupation Date of admission Religion Mother tongue Monthly income LMP EDD Obstetrical score : : : : : : : : : : : :

ANTENATAL HISTORY First trimester

Second trimester

Third trimester

FAMILY HISTORY Type of family No of working members Any chronic disease/hereditary diseases

FAMILY TREE

SOCIO ECONOMIC BACKGROUND Ability to afford hospital expenses: Financial assistance :

PAST MEDICAL OR SURGICAL HISTORY

MENSTRUAL HISTORY Age of menarche Menstruation Flow Frequency Duration : Regular / Irregular :Mild/ Moderate/ Severe : :

MARITAL HISTORY Duration of married life : Type of marriage :Consanguineous/ Non consanguineous

PAST OBSTETRIC HISTORY

SINO DT/YEAR OF DELIVERY PLACE OF BIRTH DURATION OF PREGNANCY METHOD OF DELIVERY PUERPERIUM SEX AND WEIGHT REMARK

PERSONAL HISTORY Diet :vegetarian/ Mixed Sleep pattern Appetite Bowel and bladder pattern Habits Exercises

HEAD TO FOOT EXAMINATION

GENERAL OBSERVATION: Appearance Body built Orientation State of Nutrition: Cooperativeness:

MEASUREMENTS Height Weight Weight gained during pregnancy

TEMPERATURE Si no 1 2 3 4 Vital signs Temperature Pulse Respiration Blood pressure Patients value Normal value Remark

HEAD TO FOOT ASSESSMENT

HEAD FACE Facial puffiness Cholasma EYES EARS NOSE Appearance : Discharge : Patency : Appearance : Discharge: Hearing : Eye brows and eye lashes Conjunctiva : Sclera : Pupilary reaction: Vision Peri-orbital edema

MOUTH AND THROAT NECK General appearance : Trachea : Lymph node : Thyroid gland Lips : Tongue : Teeth : Gums : Buccal mucosa: Tonsil:

CHEST I. Breast

Inspection Primary and secondary areola : Montgomerys tubercle :

Palpation : Enlargement of lymph nodule s : Engorgement of breast : Presence of colustrum/ mil :

Auscultation: Heart rate Respiratory rate Any abnormalities

ABDOMEN Inspection Size : Shape : Contour : Umbilicus : Linea niagra & striae gravidarum: Fundal height : Fetal movements: Abdominal Scar : Abdominal girth : Palpation : Fundal Palpation:

Lateral Palpation: Left lateral palpation :

Right lateral palpation :

Pelvic Grip:

Pawlik palpation:

Auscultation: FHR Location

P.V FINDINGS Cervical dilatation : Effacement: Station : Liguor: Pelvis :

DESCRIPTION OF FIRST STAGE :

DISCRIPTION OF SECOND STAGE:

DESCRIPTION OF THIRD STAGE :

LENGTH OF LABOUR 1st stage 2nd stage 3rd stage Total hours

CONDITION OF MOTHER AFTER DELIVERY Pulse : Blood plessure: Fundal height: Uterus : Vaginal bleeding: Total blood loss:

CONDITION OF PUERPERIUM Episiotomy type: Type of suturing Material used :

PLACENTAL DETAILS: Weight Cord length Complete/ incomplete

CONDITION OF BABY Weight: Cry Apgar score: 1st minute 2nd minute

DRUGS GIVEN FOR MOTHER sino Drug Dose Route Frequency Action Side effect

DRUGS GIVEN FOR BABY sino Drug Dose Route Frequency Action Side effect

NURSING DIAGNOSIS

HEALTH EDUCATION