LOURDES COLLEGE OF NURSING – SIDHI SADAN

ANTENATAL CARE STUDY FORMAT

Sl.
CONTENT
No.
I BASELINE DATA

 Name
 Age
 I P No.
 Ward
 Marital status
 Religion
 Education
 Occupation
 Obstetrical score
 LMP
 EDD
 Gestational age in weeks
 Date of admission
 Diagnosis
 Date of discharge
II HISTORY
1. Present illness history
 Chief complaints for admission
 History of present illness and Management
2. Past obstetric history:
OB Score: GPLA

Year Type of Sex Family

delivery planning
Complications if any method
adopted

AN IN PN

3. Present obstetrical history

I Trimester II Trimester III Trimester
 4. History of antenatal visits

Date Gestati Urine Minor ailments/

onal Wt BP FHR Immunization treatment/
age Alb Sug remarks

5. Past health history

 Illness
 Treatment
 Medications / surgery
 Other managements
6. Menstrual history
 Age of onset of menarchae
 Cycles - regular/ irregular(no: of days / frequency of cycle)
 Any discomfort associated with menstruation
7. Personal history
 Nutrition
 Habits
 Elimination
 Exercise
 Rest and sleep
8. Family history
 Type : Joint/ Nuclear/extended
 No. of members
 Support person
 Any illness – TB, DM, HT, Heredity etc.( related to present condition of the
mother)
9. Environmental history
 Health care facility
 Housing
 Water
 Drainage
10. Socio-economic and cultural background
 Social class
 Family income
 Relationship with family members & neighbours
 Any specific customs
 Food habits
11. Mental and emotional status
III ANTENATAL EXAMINATION
a. Physical examination
 Body built
 Height
 Weight
 Posture
 Gait
  Grooming
 Vital signs : Temperature, Pulse, Respiration, B.P
 Head, Eyes, Ear, Face, Nose, Mouth, Neck, Lymphnodes
 Breast
 Respiratory system
 Cardiovascular system
 GI system
 Genitourinary system
 Musculoskeletal system
 Integumentary system
 Central nervous system
b. Abdominal examination
a. Inspection
 Size  Skin changes  Umbilicus
 Shape  Bladder  Flanks
 Contour  Fetal movements  Any other

b. Palpation
i. Abdominal girth
Height of fundus
in weeks
in centimetres
ii. Lateral palpation
Right
Left
iii. Pelvic palpation
Grip I
Grip II
c. Auscultation

 FHR
 Rate
d. Findings

 Lie  Position
 Attitude  Engagement
 Presentation  FHR

IV INVESTIGATIONS

Date Specimen Examination Result Normal value Interpretation

 Radiographic (date)

V MEDICATIONS

Drugs/ Route/ Dose Action Side effects Nurse’s responsibility

Pharmacological Name
VI DIET PLAN
 Recommended calories
 Plan a day menu

VII DISEASE ASPECT ( book picture should be compared with patient picture in detail)

a.Definition
b.Etiology and predisposing factors
c.Pathophysiology
d.Clinical manifestations
e.Diagnostic measures
f.Medical management
- Definitive
- Supportive
g. Complications
h. Prevention
VIII NURSING MANAGEMENT
 List of nursing problems according to priority
 Nursing process
IX DAILY NURSE’S PROGREESS NOTE

X DISCHARGE PLAN AND HEALTH EDUCATION

XI CONCLUSION

XII BIBLIOGRAPHY