INDENTIFICATION DATA

PATIENT’S DATA STUDENT’S DATA

 Name-  Name of student-

 Age –  Class-
 Address-  Date of care started-
 Registration Number-  Date of care ended-
 Educational status-  Number of nursing care plan-
 Occupation-  Number of days care-
 Family Income-
 Religion-
 Duration of Marriage-
 Obstetrical score- GP AL
 LMP-
 EDD-
 Period of Gestation-
 Date of Admission-
 Time-
 Diagnosis-

CHIEF COMPLAINTS
PRESENT HISTORY OF ILLNESS: medical/ surgical
PAST HISTORY OF ILLNESS- medical/ surgical
MENSTRUAL HISTORY:
 Age of menarche-
 Regularity-
 Flow –
 Dysmenorrhea-
 L.M.P.-
 E.D.D-
 Period of gestation-
 MARITAL HISTORY:
 Age at marriage-
 Duration of marriage-

OBSTETRIC HISTORY:
 Obstetrical score – GP A L

S NO YEAR NATURE OF PREGNANCY NATURE OF LABOUR NATURE OF SEX

PUERPERIULM

PRESENT PREGNACY RECORD

 Date of Booking/Registration
 Period of gestation-
 Immunization during pregnancy-
 Iron and folic Acid supplements-
TRIMESTER HISTORY-
 FIRST TRIMESTER-
 SECOND TRIMESTER-
 THIRD TRIMESTER

INDIVIDUAL HEALTH HISTORY

PERSONAL HISTORY

 Hygiene :
 Dietary pattern
 Sleep
 Elimination
 Social relations :
  Activities :
 Substance abuse :
 Use of contraception :
 Hobbies

DIET PATTERN

Breakfast Lunch Dinner

Socio-economic status: Monthly income

Working person -
Family members -
Per-capita income -
SOCIO ECONOMICAL HISTORY-
FAMILY HISTORY

FAMILY TREE:

FAMILY COMPOSITION:

There is no significant history of any illness in the family like hypertension, diabetes mellitus or any other communicable diseases.

S NO NAME AGE SEX RELATIONSHIP EDUCATION OCCUPATION MARITAL HEALTH

WITH PATIENT STATUS STATUS

PHYSICAL EXAMINATION:
GENERAL APPERANCE- Done on

 Name of the patient-

 Gender And Race-
 Body Built-
 Gait-
 Nourishment-well-nourished BMI=Weight(kgs)/(height(cms))
Health-
 Activity-
 Appearance-
 Mental Status-
 Posture-
 Height-
 Weight-
 Age-
 Posture-
 Nutritional status-

VITALS:
 Temperature-
 Pulse-
 Respiration-
 Blood pressure-

MENTAL STATUS:
 Consciousness –
 Look-

HEAD TO TOE EXAMINATION

SKIN CONDITION-
 Colour-
 Moisture-
 Texture-
 Temperature-
 Turgor-
 Edema-
 Lesions-

HEAD AND SCALP:

 Shape of the skull-

 Scalp-
 Colour-
 Texture-
 Alopecia-
 Distribution-
 Dandruff-

FACE

 Edema- Absent/present
 Palsies- Absent/present
 Petechiae - Absent/present
 Cholasma - Absent/present

EYES
 Operation History-
 Eye-brows-
 Movements-
 Eyelids-
 Eyelashes-
 Eyeballs-
 Colour-
 Conjunctiva-
 Pupil-
 Vision-
 Edema-
EAR

 Alignment-
 Discharge-
 Swelling-
 Wax-
 Hearing –

NOSE
 Symmetry-
 Discharge-
 Septum-
 Mucous membrane-
 Nasal flaring-

NAILS

THROAT AND NECK

 Neck movement-
 Lymph node-
 Range of motion-

MOUTH
 Lips-
 Odour-
 Teeth-
 Tongue-
 Gums-
 Palate-
 Mucous membrane-
 CHEST AND LUNGS
 Nipple-
 Symmetry-
 Breath pattern-
 Sound-

BREAST:
 Size-
 Shape
 symmetry
 Nipple-
 Areola-
 Lymph nodes(palpation method)

BACK

ABDOMINAL EXAMINATION
 Inspection-
 Palpation
Fundal height –
Abdominal girth-
Weeks of gestation according to fundal height-

OBSTETRIC GRIPS-
 Fundal grip
 Lateral grip
 Pelvic grip
 Pawlik grip

AUSCULTATION-
FHS-

EXTREMITIES
 GENTALS

RECTUM AND ANUS

NEUROLOGICAL TEST
 Achilles’ Reflex-
 Biceps Reflex-
 Deep Tendon Reflex-
 Patellar Reflex-
 Sensation-
 Emotional status-

CONCLUSION:-

 Gestational age-
 Fundal height-
 Lie-
 Presentation-
 Position-
 Denominator-
 Engagement-

INVESTIGATIONS-

S NO INVESTIGATION DONE PATIENT’S VALUE NORMAL VALUE REMARKS

ULTRASONOGRAPHY:

GESTATIONAL AGE –
PLACENTA-
AFI-
FHS –
MEDICATION:-

TRADE PHARMACOLO DOSE ROUTE FREQUECY ACTION NURSE RESPONSIBILITY

NAME GICAL NAME

NURSING DIAGNOSIS:-
FOR MOTHER

ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION EVALUATION

DIAGNOSIS

SUMMAY FOR CARE PROVIDED TO THE MOTHER:-

1st DAY
2nd DAY
3rd DAY

BABY EVALUATION:-

DAY GENERAL VITALS WEIGHT ANTHROPOMETRY MEASUREMENT

CONDITION

HEALTH EDUCATION:-

DIET PLAN:-
BREAKFAST LUNCH EVENING SNACKS DINNER

CONCLUSION:-