Format 1: PRENATAL NURSING HISTORY

Student’s name_________________________ BSN 2 Block______

Name of Clinical Instructor_________________

Components of the PRENATAL NURSING HISTORY

I. Demographic Data
A. Name
B. Age/ Date of birth/ place of birth
C. Address
D. Telephone No.
E. Religion
F. Health Insurance information
G. Date of History Taking____________

II. Chief Complaint – (the reason the woman has come to the health care setting, the fact that she is or thinks she is pregnant, may quote the patient’s
own words,) ______________________________________________________________
it may include the following:
 LMP__________
 Pregnancy test ______(Yes) ______(No)
 Signs of early pregnancy ______________
 Discomforts of pregnancy _______________
 Exposure to any contagious disease? ____________
 Has taken any medication that might be harmful to the fetus? __________
 Any danger sins of pregnancy? ____________
 Is this pregnancy planned? ____(Yes) _____(No) ; (further explore on this)

III. Family Profile (obtain a family setting history to know the woman earlier and shape the nature and kind of questions asked)
 Civil status
 Educational level

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Prof. Manuela P. Tirazona
MCN I AY 2020-2021
  Occupation
 Family support ?_______ (yes) _____(No) Name of Husband/ Partner__________________ Occupation ________
 Other member of the family the patient lives with

Name Age Gender Relation Occupation Educational attainment

    
 Environmental history (living condition, neighbourhood circumstance)

IV. Past Medical History

a. Childhood illness
b. Adult illness
c. Immunization
d. Previous hospitalization
e. Operations
f. Injuries
g. Medications
h. Allergies

V. Gynecologic History
 Menarche (age)_______
 Interval of menstruation
 Days (duration)
 Amount and characteristic
 Symptoms associated with menstruation
 Gynecologic disorders: (cyst, polyp…)

VI. Obstetric History

 LMP
 EDC
 AOG
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Prof. Manuela P. Tirazona
MCN I AY 2020-2021
  Gravidity ________
 Parity ________
 OB Score (T___P___A___L___M____)
 Maternity and birth history

Parity Birth date / year Gender Type of delivery Hospital Condition at birth Complications of Feeding history
labor and delivery types of feeding

VII. Family History (heredo-family illness) cardiovascular, renal, cognitive impairment, blood disorders, congenital anomalies
 Maternal
 Paternal

VIII. Social History

a. Lifestyle
b. Habits
c. Vices: Smoking_____ Drinking Alcohol______Drugs:________(SAD habits)
d. Social affiliation
e. Travel
f. Exercise pattern
g. Spouse abuse
h. Substance abuse

IX. Hygiene of Pregnancy ( a Typical Day information about a woman’s current nutrition, elimination, sleep, recreation}

Before pregnancy During pregnancy

Nutrition
Elimination
Sleep and rest
Recreation
Hygiene

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Prof. Manuela P. Tirazona
MCN I AY 2020-2021
 X. Review of System
A. General status (overall impression of your client)
B. Head
C. Eyes
D. Ears
E. Nose
F. Mouth
G. Neck
H. Breasts
I. Respiratory system
J. Cardiovascular system
K. Gastrointestinal system
L. Genitourinary system
M. Extremities

XI. Physical Assessment

A. Date and time
B. Vital signs:
 Temp
 BP
 PR
 RR
C. Regional Examination (Indicate findings using descriptive forms, Inspection, palpation, percussion, auscultation

Region / body system Method of Normal findings Actual findings Deviation from
inspection normal
1. Skin
2. Nails
3. Head and face
4. Eyes

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Prof. Manuela P. Tirazona
MCN I AY 2020-2021
 5. Ears
6. Nose
7. Mouth and pharynx
8. Neck
9. Spine
10. Thorax and lungs
11. Heart
12. Breast
13. Abdomen
14. Extremities
15. Genitals
16. Rectum and anus

XII. Other Sources of Information

A. Drug Study
B. Laboratory Results or Findings
C. Diagnostic Tests
Reference:
Maternal and Child Health Nursing, Adele Pillitteri (Assessing Fetal and Maternal Health)
Fundamentals of Nursing, Kozier & Erb

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Prof. Manuela P. Tirazona
MCN I AY 2020-2021