COLLEGE OF NURSING, MADURAI MEDICAL COLLEGE, MADURAI – 20

OBSTETRICAL & GYNAECOLOGICAL NURSING

POSTNATAL ASSESSMENT

DEMOGRAPHIC DATA:

Name of the mother :

Age :

Educational level :

Name of Husband :

Age :

Educational level :

Religion :

Occupation :

Income :

Address :

L.M.P :

E.D.D :

Admitted on :

I.P.No. :

Ward :

Unit :

Obstetrical score :

Date of assessment :
II.REASON FOR HOSPITALIZATION/NEED FOR SEEKING HEALTH CARE:

PERSONAL HISTORY:

Nutrition : Non vegetarian/vegetarian

Frequency of meals :
Food fade :
Food allergy :
Habits : Alcohol/Smoking/Chewing pan/Using snuff/None

Drugs : Over the counter/On prescription/Allergy

Sleep :

Rest :

Hygiene :

Exercises :

Urinary pattern :

Bowel pattern :

Menstrual history :
Marietal history :

Nutritional assessment :

SOCIO ECONOMIC STATUS:

FAMILY HISTORY:

Multiple pregnancies :

Communicable diseases :

Chronic medical diseases : Hypertension/Diabetes mellitus/Bronchial asthma/others

Mental illness :

Genetic disorder :

Any other :

MEDICAL HISTORY:

Childhood illness :

Previous illness :

Surgeries :

Any other :
OBSTETRICAL HISTORY:

Past obstetrical history:

Year of Antenatal Intranatal Postnatal Newborn Birth Breast Remarks

delivery period period period sex weight feeding

Present obstetrical history:

LMP : EDD :

D.O.D :

Term : Full term / Preterm / Post mature

Type of Delivery : Normal / LSCS / Instrumental

Drugs used during delivery :

Perineum : Intact / Episiotomy

L.P : I / II / III / IV

Repaired with :
PHYSICAL EXAMINATION:

General assessment :

Height : Weight : BMI :

Vital signs

Temperature :

Pulse :

Respiration :

Skin changes :

Pallor : Present / not present

Eyes :

Conjunctiva & sclera : pale / red / normal

Nose :

Mouth :

Neck :

Breast :

Consistency :

Nipple : normal / erect / cracked / sore / inverted

Lactation :

Chest :
Abdomen :

Bowel sounds : present / absent

Fundal height :

Uterus : involuted / sub involuted

Genitalia :

Lochia : amount : odour : colour :

Vulva : no edema / edematous

Episiotomy :

Redness :

Edema :

Ecchymosis :

Discharge :

Approximation of edges :

Micturition :

Bowel movement :

Extremities :

Symmetrical / Asymmetrical

Edema :

Redness :

Tenderness :

Homen’s sign : Positive / Negative

LAB INVESTIGATION/DIAGNOSTIC PROCEDURE:

Date Name Client Value Normal Value Remarks

OTHER SPECIFIC ASSESSMENT:

Knowledge Attitude Behaviour

Nutrition
Hygiene
Baby care
Postnatal exercise
Family planning
Any other

Family planning methods preferred:

Temporary / permanent-

Specify Reason for not prevailing

 COLLEGE OF NURSING, MADURAI MEDICAL COLLEGE, MADURAI – 20
OBSTETRICAL & GYNAECOLOGICAL NURSING

ASSESSMENT OF NEWBORN

DEMOGRAPHIC DATA

Name :

Mother’s name :

Father’s Name :

Address :

Date of birth :

Sex :

I.P.No :

Ward :

Unit :

Condition at birth :

Apgar score :1 minute------------ 5 minute-------------------

Birth order
OBSTETRICAL HISTORY:

Past obstetrical history:

Year of Antenatal Intranatal Postnatal Newborn Birth Breast Remarks

delivery period period period sex weight feeding

History of present labour/ delivery

Type of labour :

Duration :

Type of rupture of membrane:

Characteristic of amniotic fluid:

Drugs and anesthesia used :

GENERAL EXAMINATION

Vital signs

Temperature :

Heart rate :

Respiration :

Weight :

Length :
Skin :

Pink / icterus

Turgor

Vernix caseosa : Present / Absent

Nail :

Hair :

Lanugo :

Milia : Present / Absent

Mangolian spots: Present / Absent

Head
Caput succedanum / cephal haematoma / birth injury

Fontanelles / sutures:

Eyes
Symmetry / discharge / congenital cataract / squint / icterus / normal

Ears
Low set / injury / discharge / normal

Nose
Flat / normal / flaring
Mouth
Cleft lip / cleft palate /thrush / normal

Lips
Colour / drooling of saliva / tongue tie

Chest

Chest movements : normal / abnormal

Chest retraction : Present / Absent

Air entry : Right / Left

Heart

Position : Normal / Abnormal

Specify murmur / others

Abdomen
Soft / firm

Distension : Present / Absent

Bowel sounds : Present / Absent

Visible peristalsis : Present / Absent

Hernia / any other

Umbilicus

Cord bleeding : Present / Absent

Condition : healthy / Unhealthy / Any other

Testis :Descended / Undesceded

Vaginal discharge : Present / Absent

Urinary flow : Normal / Abnormal

No of times :

Rectum : Patent / Not patent

Meconeum : Passed / Not passed

Transitional stools: Color / Consistency / specify

Extremities

Syndactyl / polydactyl / acrocyanosis / CTEV

Range of motion :
REFLEXES

Feeding reflexes

Sucking reflex : Elicited / Not elicited

Swallowing reflex : Elicited / Not elicited

Rooting reflex : Elicited / Not elicited

Gag reflex : Elicited / Not elicited

Parental bonding

Blinking reflex : Elicited / Not elicited

Coughing reflex : Elicited / Not elicited

Sneezing reflex : Elicited / Not elicited

Yawning reflex : Elicited / Not elicited

Other reflexes
Tonic neck reflex : Elicited / Not elicited

Babinski’s reflex : Elicited / Not elicited

Doll’s eye reflex : Elicited / Not elicited

Stepping reflex : Elicited / Not elicited

Moro reflex : Elicited / Not elicited

Feeding pattern

Breast feeding

Time of initiation :

No of feeds per day :

Parental bonding :

Any other

Parental bonding

Behavioral adaptation :

Eye contact :

Sleep : for ---------------hrs per day

Respond to stimuli
Auditory / tactile / smell.
 College of Nursing,
Madur1ai Medical College,
Madurai-20

OBSTETRICAL & GYNAECOLOGICAL NURSING

POST NATAL ASSESSMENT

SUBMITTED TO:
MRS.SOBANA JOY JOHN MSc(N)
READER,
Miss P. Malliga, M.Sc (N)., M.A (Soc).,
Mrs S. Auyisha Sithik, M.Sc (N)., MBA SUBMITTED BY
Faculty in nursing Subbiah Nadar Amutha
College of nursing I Year M.Sc (N)
Madurai medical college College of nursing
Madurai -20 Madurai medical college
Madurai-20.
 College of Nursing,
Madurai Medical College,
Madurai-20

OBSTETRICAL & GYNAECOLOGICAL NURSING

NEWBORN ASSESSMENT
SUBMITTED TO:
Mrs. S. Lilly Puspam, M.Sc (N).,
Lecturer in nursing
Miss P. Malliga, M.Sc (N)., M.A (Soc).,
Mrs S. Auyisha Sithik, M.Sc (N)., MBA SUBMITTED BY
Faculty in nursing Subbiah Nadar Amutha
College of nursing I Year M.Sc (N)
Madurai medical college College of nursing
Madurai -20 Madurai medical college
Madurai-20