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Antenatal Assessment

This document contains an antenatal assessment form with sections for collecting information about a patient's personal and medical history, including obstetric history, present complaints, examination findings, lab results, and developing a nursing care plan. It collects details about the patient's identity, estimated due date, vital signs, physical assessment of pregnancy, and screens for medical conditions to guide care during the antenatal period.

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jyoti singh
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3K views9 pages

Antenatal Assessment

This document contains an antenatal assessment form with sections for collecting information about a patient's personal and medical history, including obstetric history, present complaints, examination findings, lab results, and developing a nursing care plan. It collects details about the patient's identity, estimated due date, vital signs, physical assessment of pregnancy, and screens for medical conditions to guide care during the antenatal period.

Uploaded by

jyoti singh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Antenatal Assessment: Covers comprehensive patient profile information necessary for an antenatal assessment, detailing personal, family, and medical background information.

ANTENATAL ASSESSMENT

1. PATIENT PROFILE:
 Name :
 Reg. No. :
 Ward No. :
 Age :
 Marital status :
 Educational status :
 Occupation :
 Husband’s name :
 Type of family :
 Per capita income :
 LMP :
 EDD :
 Marital life :
 1st Antenatal visit :
 Date of antenatal visit :
 Date admission :

 Obstetric score
o G- Gravida
o T-Term
o P-Para
o A-Abortion
o L-Live
2. PRESENT CHIFE COMPLAINS:

3. MENSTURAL HISTORY:
 Age at menarche
 Cycle-days,……………irregular…………unknown……
 Duration -days,………weeks,……………month……..
 Flow – reglar………………, irregular………
 LMP……………….
 EDD……………….
TT(TETANUS TOXOID)-
TT 1st DOSE (FIRST TRIMESTER)……………….
TT 2nd DOSE(SECOND TRIMESTER)…………….

-PAST MEDICAL ILLNESS:

-PAST SURGICAL ILLNESS:

4. SOCIO-ECONOMIC HISTORY:
A) HOUSING
 Type of house -
 Lighting -
 Ventilation-
 Water facility-
 Sanitation-
B) FOOD HYGIENE PRACTICE-

C) PERSONAL HYGIENE PRACTICE-


D) RELIGIOUS PRACTICE-

E) FAMILY INCOME &EXPENDITURE-

5. PAST OBSTETRICAL HISTORY:

S. No. Year Full Term Abortion Nature of Child


Or Or delivery Alive Sex/weight
Preterm Stillborn
6. PRENATAL VISIT :
Date Height BP Gestation Height Abdomina Prestation Position Treatment
/weight week of l Girth
fundus

7. ANTENATAL EXAMINATION:

GENERAL APPEARANNCE:

 Height :
 Weight :
 Body built : moderate /thin/obese
 Eyes : pupils normal/dilated/constriction
 Ears :
 Nose : normal/ nasal septal deviation/nasal polips/rhinitis
 Nipple : pigmentated/Montgomery’tubercles/cracked/visible
VITAL SIGN:

Temperature
Pulse
Respiration
B.P

8. ABDOMINAL EXAMINATION:
1. INSPECTION:
Abdominal size…………
Strai gravidarm …………
Shape ……………………
Any scar…………………
Contour …………………
Linea niagra ……………..
2.PALPITATION:
Abdominal girth -
Fundal height -

3.ASCULTATION:

F.H.S…………/min.
9. GENITOURINARY SYSTEM
Edema -
Colour of urine -
Nature of urine -
No dysuria and incontinence -
10. REPRODUCTIVE SYSTEM-
 Position of uterus -
 Amenorrhoea -
 Dysfunction uterine -
 Vulvo vagina -
11. LABORATORY INVESTIGATION:
 H.B%.......................
 Blood Group...............
 VDRL.........................
 HIV........................
 Blood Sugar
R………….F……………PP(POST PRANDIAL)
 Urine Test
Protein…………… Sugar ……………. Pus cell……………

12. DRUG HISTORY:

S.NO. DRUG NAME STRENGTH DOSE ROUTE


TIME ACTION SIDE EFFECT NURSING
RESPONSIBILITY

13. DISEASE DISCRIPTION:


14. LIST OF NURSING DIAGNOSIS:

15. NURSING CARE PLAN


ASSESSMENT NURSING GOAL PLANNING IMPLIMAN ELEVATION
DAIGNOSIS TATION
Subjective Objective
data data

16. HAELTH EDUCATION:

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