SHREE KRISHNA INSTITUTE OF NURSING, BHABHAR

ANTENATAL ASSESSMENT

DEMOGRAPHIC DATA

NAME :

AGE :

EDUCATIONAL STATUS :

OCCUPATION :

HUSBAND NAME :

AGE :

EDUCATIONAL STATUS :

OCCUPATION :

RELIGION :

NATIONALITY :

ADDRESS :

INCOME :

OP.NO. :

WARD :

UNIT :

DATE OF ADMISSION :

OBSTETRIC SCORE :

LMP :

EDD :

WEEKS OF GESTATION :
DIAGNOSIS :

CARE STARTED :

CARE ENDED :

INFORMANT :

REASON FOR HOSPITALISATION:

CHIEF COMPLAINTS :

PRESENT MEDICAL HISTORY

PAST MEDICAL HISTORY

PAST SURGICAL HISTORY

FAMILY HISTORY

MULTIPLE PREGNANCIES :

COMMUNICABLE DISEASES :

CHRONIC MEDICAL DISEASES :

MENTAL ILLNESS :

GENETIC DISORDER :
 FAMILY CHART

S. Relationship
Name Of The Educational Occupational Health
N Age Sex With The
Family Memebers Status Status Status
o Mothers

FAMILY TREE:

KEYS:

SOCIOECONOMIC HISTORY

PERSONAL HISTORY:

NUTRITION :

FREQUENCY OF MEALS :

FOOD FADES :

FOOD ALLERGY :

HABITS :

DRUGS :
 SLEEP PATTERN :

REST :

HYGIENE :

EXERCISE :

URINARY PATTERN :

BOWEL PATTERN :

HOBBIES :

IMMUNIZATION HISTORY :

MENSTRUAL HISTORY :

 Age at menarche :
 Duration of cycle :
 Amount of flow :
 Regular/irregular :
 Any abnormalities :

MARITAL HISTORY :

 Duration of marriage :
 Consaguinous / Non consanguinous marriage :

SEXUAL HISTORY :

CONTRCEPTIVES :

OBSTETRICAL HISTORY :

A). PAST OBSTETRICAL HISTORY:

Year Of
Antenatal Intranatal Postnatal Newborn Birth Breast
Deliver Remarks
Period Period Period Sex Weight Feeding
y
 B). PRESENT OBSTETRICAL HISTORY:

Date of booking :

Gestation at 1st visit:

LMP:

EDD:

First trimester

Second trimester

Third trimester

ATTENDANCES

Urine Height
Blood
Wt FHR of
pressure Weeks of Treatment
Date in Per fundus Presentation
Sugar

mm gestation Remarks
Alb

Kg min in
Hg
week
 PHYSICAL EXAMINATION

GENERAL CONDITION

HEIGHT :

WEIGHT :

BMI :

POSTURE :

GAIT :

VITAL SIGNS

TEMPERATURE :

PULSE :

RESPIRATION :

BLOOD PRESSURE:

GENERAL APPEARENCE

HEAD

SKIN

EYES

EARS
NOSE

MOUTH

NECK

CHEST

ABDOMEN

OBSTETRICAL EXAMINATION

BREAST

INSPECTION

SIZE :

SHAPE :

NIPPLE :

PRIMARY AREOLA :

SECONDARY AREOLA :

MONTGOMERY’S TUBERCLE :

VEINS :

PALPATION

CONSISTENCY :

DISCHARGE :

LIMB NODES :
 ABDOMEN

INSPECTION

SIZE :

SHAPE :

CONTOUR :

SKIN CHANGES :

SCAR :

UMBILICUS :

FLANK :

FETAL MOVEMENT :

LIGHTENING :

HEIGHT OF THE FUNDUS :

ABDOMINAL GIRTH :

PALPATION

FUNDAL PALPATION :

LATERAL PALPATION :

 Left side :
 Right side :

PELVIC PALPATION :

 Grip I :
 Grip II :

AUSCULTATION

SUMMARY OF FINDINGS

Lie :
Attitude :
Presentation :
Position :
Engagement :
FHS per min :

EXTREMITIES

GENETALIA

SPINE

LAB INVESTICATION

NAME PATIENT VALUE NORMAL VALUE REMARKS

IMPRESSIONS

SPECIAL INVETIGATIONS
 MEDICATIONS

S
. NAME OF THE SIDE NURSES
DOSE ROUTE FREQ ACTION INDICATION
N MEDICATION EFFECTS RESPONSIBILITY
O

HEALTH EDUCATION

NURSING DIAGNOSIS
NURSING RESPONSIBILITIES