LABOUR ASSESSMENT TOOL

BIOGRAPHIC DATA:
NAME: HOSPITAL:

AGE: WARD:

SEX: UNIT:

MARITAL STATUS: IP NO:

EDUCATION: BED NO:

OCCUPATION: DATE AND TIME OF ADMISSION:

OCCUPATION OF HUSBAND: DIAGNOSIS:

MONTHLY INCOME: GRAVIDA:

ADDRESS: PARA:

LMP:

EDD:

CHIEF COMPLAINS:
 PAST OBSTETRICAL HISTORY:

MOTHER CHILD

Complication Sex Weight Health Cause

no. of Date of Complications Complication of of of the conditi of
pregnancy delivery of pregnancy of labour peurperium the baby on death
baby

RESENT OBSTETRICAL HISTORY:

MEDICA HISTORY :
History of any:

1. Diabetes__________

2. Epilepsy__________

3. Heart disease__________

4. Asthma__________

5. Urinary tract infection_______________

6. Allergies___________________

7. Varicosities___________________

8. Hypertension___________________

9. Accidents_______________

10. Surgery___________________

11. Blood transfusion____________________

FIRST STAGE OF LABOUR:

LATENT PHASE:

Vital signs

Temperature: Onset of labour:

Pulse: Date and time:

B.P: F.H.S:

Respiration: Contractions:

Time f onset of regular contractions_______________

Frequency of contraction__________________________

Duration of contraction________________

Cervical dilatation___________________

Effacement____________________

Decent__________________

ACTIVE PHASE:

Vital signs

Temperature: Pulse:

Respiration: B.P:

Membranes :Intact_______________ Ruptured_______________

Contraction __________________

Duration________________

Cervical dilatation_________________

Decent___________

Presentation__________________

Position_______________

F.H.R_______________________-

P.V. FINDINGS:

Cervical dilatation____________-

Cervical effacement___________

Station of presenting part_______________

Pelvis: Adequate (or) Inadequate_____________

TRANSITION PHASE:

Duration___________________
Strength__________________

Frequency________________

Cervical dilatation_________________-

Decent______________________

Effacement___________________

PSYCHOLOGICAL ASSESSMENT OF THE MOTHER IN LABOUR:

Self confidence________________________

Coping menisms___________________

Maintain control during labour_____________________

Support group____________________

SECOND STAGE OF LABOUR:

Onset: date and time___________________

Contractions________________

Strength_________________

Frequency_______________

Durations______________

MATERNAL EFFORTS:

Episiotomy______________

Indication______________

Type_______________

Local anesthesia__________________

Forceps_______________________

Ventouse _________________

Cord around the neck: Yes__________________ No________________

Time of birth of baby____________

Sex of baby_________________

Birth weight_________________ inactive_________

Baby cry: present______________ Absent______________

THIRD STAGE OF LABOUR:

Signs of placement separation:

Lengthening of cord______________

Fresh bright bleeding_________________

Supra pubic bleeding______________

Method of expulsion_________________

Time of expulsion________________

Membranes complete_____________________

Incomplete________________

Placenta weight_____________

Type of placenta______________

Cord length__________

Cord vessels________________

Perineum intact / lacerated_____________

Repaired with______________________

Blood loss____________________

FOURTH STAGE:
Temperature_________________ pulse______________

Respiration___________________ Blood pressure_____________

Fundus______________________ Bleeding________________

Initiation of breast feeding_______________

INFERENCES:

NURSING DIAGNOSIS:
 ANTENATAL ASSESSMENT TOOL

IDENTIFICATION DATA:

NAME: HOSPITAL:

AGE: WARD:

SEX: UNIT:

MARITAL STATUS: IP NO:

EDUCATION: BED NO:

OCCUPATION: DATE AND TIME OF ADMISSION:

OCCUPATION OF HUSBAND: DIAGNOSIS:

MONTHLY INCOME: LMP:

ADDRESS: EDD:

CHIEF COMPLAINTS:
Onset: Sudden_______________ Gradual___________________

Duration: Hours________________ Days_______________

Severity: Mild______________ Moderate____________ Severe__________________

Reliving factors___________________

Aggravating factors__________________

RESENT OBSTETRICAL HISTORY:

FIRST TRIMESTER:

Nausea: present_________ absent__________

Vomiting: present_________ absent_________ no of times/ day ___________

before meals_____________ after meals_____________

Giddiness: present _______ absent____________ Duration____________

Burning mituraton : present________ absent____________ frequency__________

Constipation: present _____________absent_______________

Heart burn: present ______________ absent_______________

before meals_____________ after meals_____________

occationally _________________

pica: present ______________ absent_______________

leucorrhoea: present ______________ absent_______________ Mild_____________

Moderate______________ severe______________ odour_______________

Use of any drugs: yes_____________ no___________

History of viral infections: present ______________ absent_______________

Any other: yes_____________ no___________ if yes specify______________

SECOND TRIMESTER:

Heart burn: yes_____________ no___________ if yes specify Mild_____________

Moderate______________ severe__________________

Anorexia: yes_____________ no___________ if yes duration________

Backache: yes_____________ no _______________if yes specify Mild_____________

Moderate______________ severe_________________

THIRD TRIMESTER:

Constipation: yes_____________ no___________ if yes duration________

Varicose veins: yes_____________ no___________

 leucorrhoea: yes_____________ no___________ if yes duration________ flow_________

PAST OBSTETRICAL HISTORY:

S. no Date of Mode of Complications Stillbirth Baby

delivery delivery Death

Antenatal Labour Pueperium Weight

Sex

PAST MEDICAL HISTORY:

Child hood diseases_______________

Measles: yes _________no_________ if yes specify___________

Chicken pox: yes ___________ no _________ if yes specify_____________

Chronic disease:________

Asthma: yes_____ no ________ if yes specify____________

Diabetes: yes __________ no_________ if yes specify______________

Hepatitis: yes _________ no______ if yes specify_____________

Anemia: yes ________ no _______if yes specify__________ any blood transfusion__________

Accidents: yes ________ no _____ if yes specify____________

Previous hospitalization: yes _______ no ________ if yes specify______________

PRESENT MEDICAL HISTORY:

PAST SURGICAL HISTORY:

H/o of surgery yes_______ no ___ if yes _____________

Type of surgery open_______________ laparoscopic _____________

Type anesthesia local___________ general___________

Time and date______________

Complication_________________________

PRESENT SURGICAL HISTORY:

H/o surgery: yes__________ no __________ if yes specify_________

Type of anesthesia:___________ local __________or general_________ spinal_____________

 FAMILY HISTORY:
PIE DIGREE:

s. no Name of the family age sex education occupation Annual Health

member income status

PERSONAL HISTORY:
Rest and sleep: hours of sleep_________ hours of rest _______

Habits time of : _______alcohol__________ pan chewing________

Dietary pattern: type of food________ veg ______ non veg _______ wheat________ jowar ____
 No of times food taken per day:_____________

Bowel and bladder: frequency ___________

Regular ____________ irregular_____________

Constipation_____________ diarrhea___________

SOCIO ACONOMIC HISTORY:

Type of house: kachha ____________ pakka_______ no of rooms_____________

Lightinig ____________ ventilation _____________

Drainage: closed_________________ open____________________

Laterine: yes_______________ no _____________

Water supply: well_____________ bore well ________ tap water _____________

MARITAL HISTORY:
Consanguvious marriage: yes________ no____________

Type of family: nuclear ____________ joint _____________

MENSTRUAL HISTORY:
Age of attining menarche:

Duration:

Interval of cycle:

Any dysmennorhea:

Pre menstrual symptoms:

FAMILY PLANING HISTORY :

Type of method used: temporary________ permanent_____________

Duration: months___________ weeks__________ days_________

Side effects: yes _______ no ____________

 PHYSICAL EXAMINATION

GENERAL APPEARANCE:
consciouness: semi conscious____________ unconscious___________ drowsy____________

Body bulid : emancipated __________ thin______ moderate__________ obese____________

Activity: mild __________ moderate___________ heavy__________

Health status: healthy____________ acutely ill____________ chronically ill _______________

MEASURMENTS:
Weight:

Height:

HEAD :
Hair:

Scalp:

Dandruff:

FACE:
Puffiness: present _______________ absent______________

Chloasma gravidaram: present______________ absent_______________

EYES:
Eyebrows:

Eye lashes:

Eye lids:

Conjectiva:

Sclera:

Papillary reaction:

Vision:

NOSE:
Discharges:

Sense of smell:

EARS:
Discharges:

Hearing:

MOUTH:
Lips: dry_____ moist_______ pale_______

Gums: pink________ bleeding______ angular stomatitis________

Teeth: perminant________ temporary________discoloration________ dental caries_________

Missingteeth________ brokenteeth_______cappedteeth_______flourosis__________

Tongue: pale____swelling________pigmented__________

NECK:
Enlargement of lymph nodes_________sub mandible________ sub clavicle__________

thyroid gland enlargement___________

CHEST:
Shape:

Heart sounds: cardiac murmurs________ palpitation_____________

Breath sounds: vesicular sounds_________ wheezing_________ crepitation__________

Pleural rub____________

Breast: symmetric_________ asymmetric primary areola_______ secondary areola__________

Normal___ color________ montogemetry tubercles_______________

Masses________ Discharge______enlarge________ tender________ nontender_______

Movable_______ fixed_______

NIPPLES:
Normal___________ inverted__________ retracted________ cracked________

ABDOMEN:

INSPECTION:

Size: appropriate__________ inappropriate_______

Shape: round________ oval_______ symmetrical___________ linea nigra________

Skin changes: color____ texture_____ discolourization________ linea nigra________

linea alba __________ Straegravidarium________

previous lscs scar_______________

Umbilicus: protruded___________ inverted_________ herniated___________

Fetal movement: present__________ absent________ FHS___________

Flankful: present___________ absent______________

Cortons: relaxed__________ elastic___________

Height of uterus_______ fundal height___________

Abdominal gurth:_____________

PALPATION:

Fundal palpation :
Lateral palpation:

Left side:

Right side:

Grip1:

presentation: engaged_______ not engaged____________

Grip2:

Attitude: flexed__________ relaxed________ mobile

AUSCULTATION:

Heart :S1- S2________ murmors_______

Fetal heart sound: present __________ absent_______ location______ rhythm_______

Presentation:_______________

Position______________

Lie_______________

Engagement:________________

EXTREMITIES:
Upper extremities:

Oedema: present _______ absent____________

Cyanosis: present_________ absent_____________

Lower extremities:

Oedema: present__________ absent___________

Cyanosis: present___________ absent___________

SPINE:
Lordosis:

GENITLIA:
Labia major:
Labia minor:

Clitoris:

Vagina:

VITAL SIGNS:
Temperature:

Pulse:

Respiration:

Blood pressure:

INVESTIGATIONS:

Name of
investigations Normal values Patient values remarks

NURSING DIAGNOSIS:
 POST NATAL ASSESSMENT TOOL

BIOGRAPHIC DATA:
NAME: HOSPITAL:

AGE: WARD:

SEX: UNIT:

MARITAL STATUS:

MARRIED: UNMARRIED:

WIDOW: DIVORCED:

RELIHION:

NATIONALITY: IP NO:

EDUCATION: BED NO:

OCCUPATION: DATE AND TIME OF ADMISSION:

OCCUPATION OF HUSBAND: DIAGNOSIS:

MONTHLY INCOME: DATE OF DELIVERY:

ADDRESS: POSTNATAL DAY:

 CHIEF COMPLAINS:

PAST OBSTETRICAL HISTORY:

delivered grevida para Period Date of Pregnancy Labor Mode puerperim

of delivery events events of child
gestation delivery
age sex
Birt
h
wei
ght

PRESENT OBSTETRICAL HISTORY:

 GYNECOLOGICAL ASSESSMENT

IDENTIFICATION DATA:
NAME: HOSPITAL:

AGE: WARD:

SEX: UNIT:

IP NO:

EDUCATION: BED NO:

OCCUPATION: DATE AND TIME OF ADMISSION:

OCCUPATION OF HUSBAND: DIAGNOSIS:

MONTHLY INCOME:

ADDRESS:

CHIEF COMPLAINTS:
HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY:

Hypertention : yes__________ no_______ if yes specify_______________

Diabetes: yes__________ no_______ if yes specify_______________

Thyroid: yes__________ no_______ if yes specify_______________

Epilepsy: yes__________ no_______ if yes specify_______________

PAST SURGICAL HISTORY:

Date of surgery:__________

type of surgery:open____________ laproscopic_____________

type of anesthesia: local___________ general____________

complication:________________

PRESNT SURGICAL HISTORY:

Date of surgery: ____________

Type of surgery: open ____________ laproscopic_______________

Type of anesthesia: local ____________ general__________

Complication:____________________
OBSTETRIC HISTORY:
Number of children:

History of previous pregnancies:

Length of gestation:

Date and time of delivery:

MENSTRUAL HISTORY:
Age at menarche:

Duration of cycle:

Amount of bleeding:

Dysmenorrheal:

MARAITAL HISTORY:
duration of marriage:

history of consanguinity:

FAMILY PLANNING HISTORY:

type of contraception: temporary__________ permanent_____________

duration:____________

side effects:

SOCIO ECONOMIC HISTORY:

type of house: kachaa____ pakka_______

lighting: adequate____________ inadequate_____________

drainage: closed_____________ open___________

water supply: bore______ well________ tap water________

 PERSONAL HISTORY:
Habits:smoking_______ drinking_______

Rest:____________________

Diet:veg________ nonveg________ mixed___________

Bowel and bladder:regular___________ irregular_____________

FAMILY HISTORY:

Pedigree:

s. no Name of the family age sex education occupation Annual Health status
member income
 PHYSICAL EXAMINATION
General appearance : thin_____ obese_____ emancipated____

Activity:mild_____ moderate_____ heavy_______

HEAD :
Hair:

Scalp:

Dandruff:

Chloasma gravidaram: present______________ absent_______________

EYES:
Eyebrows:
Eye lashes:

Eye lids:

Conjectiva:

Sclera:

Papillary reaction:

Vision:

NOSE:
Discharges:

Septal deviation:

EARS:
Discharges:

Hearing:

MOUTH:
Lips: dry_____ moist_______ pale_______

Gums: pink________ bleeding______ angular stomatitis________

Teeth: perminant________ temporary________discoloration________ dental caries_________

Missingteeth________ brokenteeth_______cappedteeth_______flourosis__________

Tongue: pale____swelling________pigmented__________

NECK:
Enlargement of lymph nodes_________sub mandible________ sub clavicle__________

thyroid gland enlargement___________

CHEST:
Shape:

Heart sounds: cardiac murmurs________ palpitation_____________

Breath sounds: vesicular sounds_________ wheezing_________ crepitation__________

Pleural rub____________

Breast: pain______

NIPPLES:
Normal___________ inverted__________ retracted________ cracked________

ABDOMEN:

INSPECTION:

Size: appropriate__________ inappropriate_______

Shape: round________ oval_______ symmetrical___________ linea nigra________

presentation: engaged_______ not engaged___________

PALPATION:

AUSCULTATION:

Heart :S1- S2________ murmors_______

EXTREMITIES:
Upper extremities:

Oedema_______ pain__________

Lower extremities:

Pain______ DVT_________

GENITLIA:
Labia major:

Labia minor:

discharge:

any signs of infection:

VITAL SIGNS:
Temperature:

Pulse:

Respiration:

Blood pressure:

INVESTIGATIONS:

Name of
investigations Normal values Patient values remarks

TREATMENT:
Name of the drug dose route action Side effects Nsg responsibilities

NURSING DIAGNOSIS: