​POSTNATAL ASSESSMENT

IDENTIFICATION DATA

Name ​I​pno
Age ​W​ard
Sex ​ ​nit
U
Education ​D​iagnosis
Duration of marriage ​D​octorsname
Occupation ​ ​ate of delivery
D
Occupation of husband

CHIEF COMPLAINTS

Onset
Duration

History of present illness

PAST OBSTETRICAL HISTORY

Date of Mode complications death Stil Baby
deliver of l conditio
y delive antenatal labour postnatal birt n
ry h
PRESENT OBSTETRICAL HISTORY

Antenatal history
No of antenatal visits
Vaccination
Complications
LMP
EDD

Intranatal history
Date of delivery

Place of delivery

Type of delivery ;

Duration of delivery

Complications

postnatal history
Lochia

Colour

Amount

Odour

A​ny signs of infection

FAMILY HISTORY

pedigree
sn Name of ag se education occupatio Annual Healt
o familyme e x n incom h
mber e status

PERSONAL HISTORY
Rest and sleep
Habits
Dietary pattern
Bowel and bladder

PHYSICAL EXAMINATION

GENERAL APPEARANCE
Consciousness
activity

Body built

Weight
height
Fundal height

Face

EYES

Eyebrows

Eyelashes
Conjuctiva

Sclera
Papillary reaction
vision

Nose

Discharges

sense of smell

ears

discharges

hearing

mouth

​L​ips
G​ums
T​eeth
​T​ongue

neck
enlargement of lymph nodes ,thyroid gland

movement

chest

H​eart sounds

B​reathsounds

breast

nipple
EXTREMITIES

U​pper extremities

L​ower extremities

SPINE
L​ordosis

GENTILIA

labia majora

labia minora

vagina

VITAL SIGNS
T​emperature
pulse
​ ​espiration
R
​ ​lood pressure
B

NEWBORN ASSESSMENT

general appearance

activity

consciousness

cry

ANTHRPIOMETRICMEASUREMENTS

weight

height
head circumference

chest circumference
SKIN
C​olour

T​exture

laniguo

birthmarks

stork bites
mangolian

spots

cyanosis

HEAD

hair

fontanel

size

shape

EYES

eyebrows

eyelashes

conjuctiva

sclera

pupillary reaction
vision

NOSE
 discharges

septal deviation

EAR

MOUTH

NECK

CHEST

heart sounds

breath sounds

ABDOMEN
shape

umbilical cord

EXTREMITIES
upper extremities

lower extremities

GENTELIA

REFLEXES

​M​oros reflexes

G​rasping reflexe

S​ucking

T​onic neck reflex

 babniski

olls eye reflex

APGARSCORE

Total score
indicator 0 1 2 3

Activity

Pulse

Grimace
(reflex)

appearance

respiration

INVESTIGATIONS

sno Name of investigation Patient value Normal value remarks

 TREATMENT

sno nameofmedication dos classification action indication contraindicati Side Nsg

e on effects responsibilitites

IMMUNIZATION

NURSING DIAGNOSIS