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Labour Tool
Labour Tool
BIOGRAPHIC DATA:
NAME: HOSPITAL:
AGE: WARD:
SEX: UNIT:
ADDRESS: PARA:
LMP:
EDD:
CHIEF COMPLAINS:
PAST OBSTETRICAL HISTORY:
MOTHER CHILD
1. Diabetes__________
2. Epilepsy__________
3. Heart disease__________
4. Asthma__________
6. Allergies___________________
7. Varicosities___________________
8. Hypertension___________________
9. Accidents_______________
10. Surgery___________________
Vital signs
B.P: F.H.S:
Respiration: Contractions:
Duration of contraction________________
Cervical dilatation___________________
Effacement____________________
Decent__________________
ACTIVE PHASE:
Vital signs
Temperature: Pulse:
Respiration: B.P:
Contraction __________________
Duration________________
Cervical dilatation_________________
Decent___________
Presentation__________________
Position_______________
F.H.R_______________________-
P.V. FINDINGS:
Cervical dilatation____________-
Cervical effacement___________
TRANSITION PHASE:
Duration___________________
Strength__________________
Frequency________________
Cervical dilatation_________________-
Decent______________________
Effacement___________________
Coping menisms___________________
Support group____________________
Contractions________________
Strength_________________
Frequency_______________
Durations______________
MATERNAL EFFORTS:
Episiotomy______________
Indication______________
Type_______________
Local anesthesia__________________
Forceps_______________________
Ventouse _________________
Lengthening of cord______________
Method of expulsion_________________
Time of expulsion________________
Membranes complete_____________________
Incomplete________________
Placenta weight_____________
Type of placenta______________
Cord length__________
Cord vessels________________
Repaired with______________________
Blood loss____________________
FOURTH STAGE:
Temperature_________________ pulse______________
Fundus______________________ Bleeding________________
NURSING DIAGNOSIS:
ANTENATAL ASSESSMENT TOOL
IDENTIFICATION DATA:
NAME: HOSPITAL:
AGE: WARD:
SEX: UNIT:
ADDRESS: EDD:
CHIEF COMPLAINTS:
Onset: Sudden_______________ Gradual___________________
Reliving factors___________________
Aggravating factors__________________
occationally _________________
SECOND TRIMESTER:
Moderate______________ severe__________________
Moderate______________ severe_________________
THIRD TRIMESTER:
Chronic disease:________
Complication_________________________
PERSONAL HISTORY:
Rest and sleep: hours of sleep_________ hours of rest _______
Dietary pattern: type of food________ veg ______ non veg _______ wheat________ jowar ____
No of times food taken per day:_____________
Constipation_____________ diarrhea___________
MARITAL HISTORY:
Consanguvious marriage: yes________ no____________
MENSTRUAL HISTORY:
Age of attining menarche:
Duration:
Interval of cycle:
Any dysmennorhea:
GENERAL APPEARANCE:
consciouness: semi conscious____________ unconscious___________ drowsy____________
MEASURMENTS:
Weight:
Height:
HEAD :
Hair:
Scalp:
Dandruff:
FACE:
Puffiness: present _______________ absent______________
Eye lashes:
Eye lids:
Conjectiva:
Sclera:
Papillary reaction:
Vision:
NOSE:
Discharges:
Sense of smell:
EARS:
Discharges:
Hearing:
MOUTH:
Lips: dry_____ moist_______ pale_______
Missingteeth________ brokenteeth_______cappedteeth_______flourosis__________
Tongue: pale____swelling________pigmented__________
NECK:
Enlargement of lymph nodes_________sub mandible________ sub clavicle__________
CHEST:
Shape:
Pleural rub____________
Movable_______ fixed_______
NIPPLES:
Normal___________ inverted__________ retracted________ cracked________
ABDOMEN:
INSPECTION:
Abdominal gurth:_____________
PALPATION:
Fundal palpation :
Lateral palpation:
Left side:
Right side:
Grip1:
Grip2:
AUSCULTATION:
Presentation:_______________
Position______________
Lie_______________
Engagement:________________
EXTREMITIES:
Upper extremities:
Lower extremities:
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:
IDENTIFICATION DATA:
NAME: HOSPITAL:
AGE: WARD:
SEX: UNIT:
IP NO:
MONTHLY INCOME:
ADDRESS:
CHIEF COMPLAINTS:
HISTORY OF PRESENT ILLNESS:
complication:________________
Complication:____________________
OBSTETRIC HISTORY:
Number of children:
Length of gestation:
MENSTRUAL HISTORY:
Age at menarche:
Duration of cycle:
Amount of bleeding:
Dysmenorrheal:
MARAITAL HISTORY:
duration of marriage:
history of consanguinity:
duration:____________
side effects:
Rest:____________________
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____
HEAD :
Hair:
Scalp:
Dandruff:
EYES:
Eyebrows:
Eye lashes:
Eye lids:
Conjectiva:
Sclera:
Papillary reaction:
Vision:
NOSE:
Discharges:
Septal deviation:
EARS:
Discharges:
Hearing:
MOUTH:
Lips: dry_____ moist_______ pale_______
Missingteeth________ brokenteeth_______cappedteeth_______flourosis__________
Tongue: pale____swelling________pigmented__________
NECK:
Enlargement of lymph nodes_________sub mandible________ sub clavicle__________
CHEST:
Shape:
Pleural rub____________
Breast: pain______
NIPPLES:
Normal___________ inverted__________ retracted________ cracked________
ABDOMEN:
INSPECTION:
PALPATION:
AUSCULTATION:
EXTREMITIES:
Upper extremities:
Oedema_______ pain__________
Lower extremities:
Pain______ DVT_________
GENITLIA:
Labia major:
Labia minor:
discharge:
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: