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

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 :
 PAST OBSTETRICAL HISTORY

s Date Mode of Complications death Still Baby

n of delivery birth conditio wt
Antenatal labor puperium
o deliv n
ery

PRESENT OBSTETRICAL HISTORY

Hypertension_____ bleeding_____ diabetes______

PAST MEDICAL HISTORY

Childhood disease
Measles : yes_____ no_____
Chickenpox : yes___ no___
Chronic diseases
Asthma : yes___ no___if yes specify________
Diabetes :yes___ no___if yes specify________
Epilepsy : yes___ no___if yes specify________
Hepatitis : yes____no___if yes specify_______
Anemia : yes ___no___if yes specify_______
Previous : yes __ no___ if yes specify________
Hospitalization

PRESENT SURGICAL HISTORY

H/o of surgery : yes ____ no_____ if yes specify___
Type of anaesthesia : local ___or general______ spinal __________

PAST SURGICAL HISTORY

H/o of surgery : yes____ no___ If yes specify___
Type of surgery :open ____ laproscopic_____
Type anesthesia : local_____ general____
Time and date :
Complications :
 FAMILY HISTORY
pedigree

sno Name of Age Sex education occupation Annual Health

familymember income status

PERSONAL HISTORY
Rest and sleep : hours of sleep _________ hours of rest________
Habits : smoking________ alcohol_________ pan chewing_______
Dietary pattern : veg______ nonveg_______ mixed_________
Bowel and bladder : regular _______ irregular_______
SOCIO ECONOMIC HISTORY
Type of house : kaccha ____ pakka______ no of rooms_____lighting_______
Ventilation_____________
Drainage : closed______ open-________
Water supply : well ______ borewater______ tapwater________

MARITAL HISTORY
Duration of marriage :
Consanguineous marriage : yes______ no______
Type of family : nuclear______ joint_________

MENSTRUAL HISTORY
Age at menarache :
Duration :
interval of cycle :
flow :scanty _____moderate_____ heavy____ clots______
dysmenorrhea :

PHYSICAL EXAMINATION
GENERAL APPEARANCE
Consciousness : semiconscious______ conscious________
Activity : mild_____ modertate ________ heavy _________
Body built : emancipated _____ thin_______ moderate________ obese________
Weight :
Height :

Head
Hair :
Face :

EYES
Eyebrows :
Eyelashes :
Conjuctiva :
Sclera :
Pupillary reaction :
Vision :

NOSE
Discharges :
Sense of smell :

EARS
Discharges :
Hearing :

MOUTH
Lips : dry_____ moist_____ angular stomatitis______
Gums : bleeding________ inflammation____
Teeth : discoloration_______ dental caries_______
Tongue : pale_____ coated_____ glossitis______

NECK
Enlargement of lymph nodes :
,thyroid gland
Range of motion :
CHEST
Heart sounds : clear_________ cardiac murmurs______ palpitations_______
Breathsounds : clear ________- vesicular sounds __________ wheezing_____________
crepitations_________
breast : painful ______ tenderness________ engorged__________
nipple :cracked _________ retracted________
secondary areola :present__________ absent___________

ABDOMEN
Inspection : skin changes_____ lscs scar__________
palpation : fundal height_____ rectus diastesis______

EXTREMITIES
Upper extremities : oedema present_______ absent________
Lower extremities : oedema present __________ absent__________
Homans’ sign_____ positive ___ negative_____

SPINE
Lordosis

GENTILIA
labia majora :
labia minora :
discharge :

VITAL SIGNS
Temperature
pulse
Respiration
Blood pressure

NEWBORN ASSESSMENT
GENERAL APPEARANCE
Activity : active________ dull________
Consciousness : semiconscious________ drowsy__________
Cry : weak ________strong__________

ANTHRPIOMETRICMEASUREMENTS
Weight :
Height :
Head circumference :
Chest circumference :

SKIN
 Colour :
Texture :
Lanugio :
Birthmarks :
Stork bites :
Mangolian spots :
Cyanosis :

HEAD
Hair :
Fontanel :
Size :
Shape :

EYES
Eyebrows :
Eyelashes :
Conjuctiva :
Sclera :
Pupillary reaction :
Vision :

NOSE
DIscharges :
Septal deviation :

EAR
Discharges :
Pinna :

MOUTH
Lips : dry____ moist_____-
Gums : bleeding______ inflammation_____-
Precocious
dentition : present________ absent____-
Tongue :pale____ coated_____

NECK
Range of motion :

CHEST
heart sound : clear______ cardiac murmurs ______ palpitations_______
breath sounds : clear___________ wheezing______
shape : symmetry______ asymmetry_______
 witch milk : present________ absent_______

ABDOMEN
Inspection :
Palpation :
Percussion :
Auscultation :
u

EXTREMITIES
Upper extremities : cyanosis present _______ absent______
clubbing of fingers present_______ absent_________
Lower extremities : cyanosis present________ absent_______
clubbing of foot present_______ absent__________

GENTELIA

REFLEXES

REFLEXES STIMULUS RESPONSE AGE OF AGE OF

APPEARANCE DISAPPEARANC
E
ROOTING

SUCKING

SWALLOWING

GRASPING

TONIC NECK
REFLEX

BABINSIKI

DOLLS EYE

STARTLE
APGARSCORE

Indicator 0 1 2 3
Activity

Pulse

Grimace
(reflex)

appearance

respiration

Total score

INVESTIGATIONS

S.NO NAME OF INVESTIGATION PATIENT VALUE NORMAL VALUE REMARKS

 TREATMENT

sn Name of dose classificatio actio indicatio Contraindicati Side Nsg

o medication n n n on effects responsibilities

IMMUNIZATION