PSP NURSING COLLEGE
TAMBARAM-KANCHIPURAM MAIN ROAD ,SRIPERUMBUDUR
TALUK,ORAGADAM
MIDWIFERY/OBSTETRICS AND GYNECOLOGY (OBG) NURSING - I including
SBA module
Antenatal assessment
Demographic data : (Including Husband name)
Age :
Occupation :
Religion :
Address :
I.P.No :
Ward :
LMP :
EDD :
Obstetrical score :
Gestational age :
Reason for hospitalization:
Chief complaints :
Family History:
H/o communicable, non-communicable and major mental disorders
Personal history:
Family type
Child hood illness – H/o of major child hood illness like head injury, fever with
sore throat, any blood transfusion, and drug allergies
Coping ability
Education status
Sleep and rest – adequate/ inadequate
Bladder and bowel pattern
Leisure time activities
Past medical and surgical history:
Menstrual history:
Age at menarche :
Menstrual cycle :
Flow :
Any discomforts during menstruation:
Marital history:
Consanguineous / non-consanguineous marriage
Married since
Contraceptives
Past obstetrical history:
S.no Year of Antenatal Intranatal Postnatal Breast New Current
Delivery Feeding born Health
Health Status
status
Mention 3 Place of Specific/ EBF or
trimester birth: uneventful not
Events If Lscs
Indication
Present obstetrical history:
First trimester Second trimester Third trimester
Registration at & weeks: Immunization: Growth scan:
Investigations : Investigation:
- USG
Complaints: IFA tablets
Anomaly scan:
Antenatal check-up:
Date of Weight Urine BP Weeks Fundal Presenta
visit (Kg) Albumi Sugar of height -tion
n gestation (cm/
wks)
Physical examination
Gait :
Head :
Face :
Eyes :
Ears : Hearing acquity normal / abnormal
Nose :
Neck :
Mouth :
Axilla : No palpable lymph nodes
Chest :
Breast :
Size
Symmetrical/Asymmetrical
Nipple
No lumps
Abdominal examination:
Inspection :
Size
Shape
Linea nigra
Straie gravidarum
Umbilicus
Contour
Flanks
Visible fetal movements
Any previous scar
Fundal palpation:
Abdominal girth
Fundal height
Findings
Lateral palpation :
Right:
Left:
Pelvic palpation:
Grip I:
Grip II:
Auscultation:
FHR : - /mt
Rhythm : Regular/Irregular
(mention the auscultation point)
Findings:
Lie :
Attitude :
Presentation :
Position :
Engagement :
Upper & lower extremities:
Range of motion
Varicose vein
Pedal edema
Perineum:
Any vulval edema
Investigation :
S.n Patient value Normal value Remarks
o
Medications:
S.no Name of the Dose Route Frequency
Drug
Vital signs:
Temperature :
Pulse :
Respiration :
Blood pressure :
BMI :
Theory application:
Nursing diagnosis
Health education: (Appropriate only not all like personal hygiene)
Documentation:
