postnatal mother Assessment

1. POSTNATAL - ASSESSMENT
INTRODUCTION:
DEFINITION:
OBECTIVES:

2. HISTORY TAKING:
I.DEMOGRAPHIC DATA:
Name
Age
I.P.No
Education
Date of admission
Name of Husband
Religion
Language
Occupation
Booked / Unbooked
Last menstrualperiod
Expected date of delivery
Obstetricalscore
II. CHIEF COMPLAINTS:

3. III. DELIVERY DETAILS:
Type of delivery-
Date of delivery-
Time of delivery-
Blood loss-
Medications, if given-
Episiotomy-
Placenta-
IV.OBSTETRICAL HISTORY:
PASTOBSTETRICAL HISTORY:
PRESENT OBSTETRICAL HISTORY:
V. PAST HISTORY OF ILLNESS:
PASTMEDICAL HISTORY:
PASTSURGICAL HISTORY:

4. VI. FAMILY HISTORY:
VII. MENUSTRAL HISTORY:
VIII. MARITAL HISTORY:
IX. CONTRACEPTIVEHISTORY:
X. SEXUAL HISTORY:
XI.PERSONAL HISTORY:
Nutrition-diet:
Rest & Sleep:
Elimination pattern- Bowel:
Bladder:

5. Hygiene:
Habits:
XII.ANTENATAL HISTORY:
I TRIMESTER:
II TRIMESTER:
IIITRIMESTER:
NUMBER OF ANTENATAL VISITS:
IMMUNIZATION:
IRON& FOLICACID SUPPLEMENTATION:
XIII. SOCIO-ECONOMIC HISTORY:
XIV. ENVIRONMENTAL HISTORY:
XV. PHYSICAL EXAMINATION:
GENERAL APPEARANCE:
Body built:
Nourishment:
Mental status:
Height:
Weight:

6. VITAL SIGNS:
Temperature-
Pulse rate-
Respiratory rate-
Blood pressure-
HEAD TO FOOT ASSESSMENT:
Head:
Face:
Eyes:
Ears:
Nose:
Mouth:
Neck:
Chest:
Back:

7. OBSTETRICAL EXAMINATION:
Breast-
Uterus-
Genitalia:
Assessmentof Lochia:
Odour -
Amount-
Colour-
Duration-
Extremities:
Upper extremities-
Lower extremities-

8. INVESTIGATIONS:
TREATMENT:
SL.
NO
NAME
OF THE
DRUG
CLASSIF-
ICATION
DOSE ROUTE FRQU-
ENCY
MODE OF
ACTION
INDICATIONS
&
SIDE -EFFECTS
NURSE’S
RESPONSIBILITIES

9. NEW- BORN ASSESSMENT:
Name of the baby-
Mother’s name-
Sex of baby-
Date of delivery-
Time of delivery-
Type of delivery-
Apgar score-
Weight of the baby-
Anthropometric measurements-
Length of baby:
Head circumference:
Chest circumference:
Abdominal circumference:
Reflexes-