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: