Taibah University

College of Nursing
Maternal and Child Health Nursing (Clinical)
first Semester

Ante Natal Record / Nursing Care Plan

History

1-Personal & social history:

Sara Mansor Albeluwi
Mother Name ------------- Age ------------
37 years old

Level of Education…………..
Bachelor’s degree Marital Condition …………... Married
Degree of relation……………
her cousin Diagnosis………………….
Placenta praevia specified as without haemorrhage

2- Menstrual History:
Age of menarche:13--------
years Average interval between period: 3---------------
months
Duration: 3-------------
days Regular
Rhythm: ---------------------
10 / 8 / 1443
LMP: -------------------------- 24 / 5 / 1444
E.D.D: ----------------------- 32 W
GA-----
3-Medical Surgical History
A) Medical B) Surgical
N/A 1st child
Kidney disorder --------- --- *C.S--------------------------------------
N/A N/A
Cardio - Vascular---------- *Vesico - vaginal fistula--------------
N/A N/A
Diabetic------------------* Curettage------------------------------
N/A N/A
Psychological: ------------- * Major operation. --------------------
Venereal diseases
4- Family History:
N/A N/A N/A
Diabetes-------------- Multiple pregnancy -----------*Renal disorder-. ---------Hypertension
N/A N/A
----------------- *psychiatric disorders-----------------
Others--------------------------------
5-Obstetrical History:
Gravida ------------------Para------------------
4 3 Abortion ---------------
0 Stillbirth--------------
0
Intra Uterine Fetal Death-----------------------
0
No. of living children: ---------
3 0
No. of low birth weight: ------------
Age of the youngest child ----------------
11 years old
6-Previous complications:
abortion: Yes ( ) No( ✔ ) Ante partum Hemorrhage :Yes ( ) No( )
Toxemia: -Yes ( ) No(✔) Poly-hydramnios :Yes ( ) No( ) oligohydramnios Yes(
) No( ) Ectopic pregnancy: Yes ( ) No(✔)
7- Previous Delivery:
Normal Delivery: -Yes ( ) No( ) Abnormal Delivery:- Yes ( ) No( )
Cesarean section /Yes ( ) No( ) Ventose /yes ( ) No( ) Forceps/ Yes ( ) No
Postpartum complications
-Preipitate labor /Yes ( ) No( ) -Prolonged labor /Yes ( ) No( )

5
Postpartum infection/ Yes ( ) No( ) - Postpartum Hemorrhage/ Yes ( ) No( )
Neonatal complications
-Neonatal jaundice / Yes ( ) No( )
-Neonatal death / (Within one week) Yes ( ) No( )
- Others (specify):/------------------------------------ ----
8- Contraceptive methods: Yes ( ) No ( )
-IUD: Yes ( ) No( ) Duration - Pills : Yes ( ) No( ) Duration
-Condom: Yes ( ) No( ) Duration. -Diaphragm: Yes ( ) No( ) Duration.
- Others---------------------------------
General examination
Vital Signs:
1- Blood pressure: ----------------
134/ 85 mmhg mmhg 2- Temperature: --------------------C
36.3 Cْ o
3- Pulse: 98
----------------------
b/m -- b/m 4- respiration: ----------------------c/m
19 c/m
Weight: ------------------
75 Kg Kg Height: --------------Cm
150 Cm
Abnormal signs -skin edema +1 minimal - pallor
other------------
local / abdominal examination
Fundal level ----------------w
33 W
Fundal grips--------
Rt----------- Lt-------------------
1st Pelvic grips------------- 2nd Pelvic grips-----------
. Fetal heart sound ------------
122 b/m

Investigations:
Urine: N/A - Sugar N/A Ketones N/A Protein
Hemoglobin: ---------------g/dl.
N/A
Medication:
MEDICATION TIME DOSE ROUTE Side effects

Without Medication

Nursing Care Plan: