POSTNATAL ASSESSMENT

IDENTIFICATION DATA

Name Ipno
Age Ward
Sex Unit
Education Diagnosis
Duration of marriage Doctorsname
Occupation Date of delivery
Occupation of husband

CHIEF COMPLAINTS

Onset
Duration

History of present illness

PAST OBSTETRICAL HISTORY

S Date of Mode complications death Still Baby
n deliver of birt condition
o y delive antenatal labour postnatal h
ry
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

Any signs of infection

FAMILY HISTORY

pedigree
sno Name of age sex education occupation Annual Health
familymember income 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

Lips
Gums
Teeth
Tongue

neck
enlargement of lymph nodes ,thyroid gland

movement

chest

Heart sounds

Breathsounds

breast

nipple

EXTREMITIES
Upper extremities

Lower extremities

SPINE
Lordosis

GENTILIA

labia majora

labia minora

vagina

VITAL SIGNS
Temperature
pulse
Respiration
Blood pressure

NEWBORN ASSESSMENT

general appearance

activity

consciousness

cry

ANTHRPIOMETRICMEASUREMENTS

weight

height

head circumference

chest circumference
SKIN
Colour

Texture

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

Moros reflexes

Grasping reflexe

Sucking

Tonic 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 dose classification action indication contraindicati Side Nsg
on effects responsibilitites

IMMUNIZATION

NURSING DIAGNOSIS