Antenatal assessment

This file contains each criteria of health assessment of antenatal mother.

1. ANTENATALASSESSMENT
I.ProfileofMother
NameoftheMother :
Age :
HospitalNo :
EducationalStatus :
Occupation :
Religion :
Address :
NameoftheHospital :
DateofAdmission :
Ward :
LMP :
EDD :
ObstetricalScore :G P L A
Weeksofgestation :
Chiefcomplaints :
II.Socio-economicStatus:
TypeofFamily :Nuclear/Joint/Extended
BreadWinner :
Totalincomeofthefamily :
TypeofHouse :Thatched/Tiled/Terraced
OwnershipofHouse :Own/Rented
Electricity&WaterSupply :
Drainage&KitchenGarden :
Latrine&RefuseDisposal :
Ventilation :
PetAnimals :
III.FamilyHistory:
S.NoNameof
theFamily
members
AgeSexEducational
Status
Occupational
status
Relationship
withthe
mother
Health
status
b)FamilyMedicalHistory:
IV.PersonalHistory:
(a)PersonalHabits :Tobaccochewing,cigarettesmoking,alcohol,coffee,cola,tea
(b)Diet
Vegetarian/NonVegetarian :
Allergiestoanyfooditem :
Numberofmealsandsnacks/day:
Likes&Dislikesoffood :

2. (c)Sleep/Rest
Numberofhoursperday&night:
Waketimes :
Difficultiesinsleeping :
(d)Activitiesofdailyliving
Anydifficultiesexperiencedinthebasicactivities
(e)Elimination
Bowelhabits - Numberoftimesperday :
Bladderhabits - Numberoftimesduringdayandnight :
(f)MenstrualHistory
1.Ageatmenarche :
2.Durationofcycle :
3.Amountofflow :
4.Regular/Irregular :
5.Anyabnormalities :
(g)MaritalHistory
consanguineous/Nonconsanguineous
Durationofmarriage :
(h)Contraceptives :
(i)DrugHistory
DrugAllergies :
V.PastMedicalHistory&Surgicalhistory
VI.PresentMedicalHistory:
VII.PastObstetricalHistory:
S.
No.
Month
&Year
Mother Baby
Compli
cation
during
pregna
ncy
Abortion/
Preterm/
Fullterm
Typeof
Delivery
Complication
during
Puerperium
Sex Birth
Weight
Condition
atBirth
Health
Status

3. VIII.PresentObstetricalHistory:
1sttrimester:H/oNausea,vomiting,pica,Anorexia,Constipation,
Exposuretodrugs/radiation/infection/AnyOther
2ndtrimester:H/oheartburn,backache,musclecramps,Anemia,GDM,PIH,Any
Other
Quickeningfeltat:
WeightGain :Normal/Abnormal-specifykgs-
3
rd
trimester:H/oheartburn,constipation,frequencyofmicturition,AnyOther
Lightening: Yes/No
FetalMovement:Normal/Excessive/Less/NotFelt
IX.AntenatalAttendance:
DateWt
In
Kg
Urine B.P
mm
of
Hg
Weeksof
Gestation
Htof
Fundus
in
weeks
PresentationF.H.R
per
minute
Treatment
&Remarks
AlbSugar
X.PhysicalExamination:
GENERALCONDITION:
Height : cms
Weight : kgs
BMI :
Gait :
Posture :
VITALSIGNS:
Temperature :
Pulse :
Respiration :
BP :
GENERALAPPEARANCE:
BodyBuilt :
HealthStatus :
Activity :

4. MENTALSTATUS
Orientation :
Facialexpression :Normal/Anxious/Depressed
AnyOther :
HEADTOFOOTASSESSMENT
HEAD:
Hair :Clean Colour Texture
Scalp :Clean/Dandruff
AnyOtherproblems:
FACE:
Pallor :
Oedema :
Chloasma :
AnyOther :
EYES:
Vision :
Conjuntiva :
Sclera :
Eyelids :
EyeBall :
PeriorbitalOedema:
EARS:
Hearing :
AnyOther :
NOSE:
SeptalDeviation :
Anyother :
MOUTH:
Lips :
Tongue :
Teeth :
Gums :
Mucosa :
NECK:
LymphNodes :
Thyroid :
CHEST:
Movement :
Respiration :
Breathsound :
Heartbeats :
Murmur :
EXTREMITIES
Upper Lower
Edema : Edema :
Nails : VaricoseVeins :
ROM : ROM :

5. BACK:
Deformity :
Anyother :
XI.ObstetricalExamination:Antenatal
BREAST:
Inspection:
Size :
Shape :
Nipple :
AreolaPrimary :
Secondary :
Montgomery’sTubercles :
Skincolour :
Palpation:
Nodules/Lumps :
Colostrums :
ABDOMEN:
Inspection :
Shape :
Size :
Skinchanges :
Umbilicus :
Muscletone :
Contour :
Flank :
ExternalFetalmovement :
Previousscar :
Palpation:
Measurement:
HeightoftheFundus: cmsFingerBreadthMethod: wks
Abdominalgirth: cms
FundalPalpation:
Lateral:Right
Left
PelvicPalpation:GripI
GripII
Auscultation :

6. PERINEUM:
Hygiene :
Discharge :
Bleedings :
Oedema :
Pruritis :
Infection :
FINDINGS
Lie :
Presentation :
Position :
Attitude :
Engagement :
FHR :
XII.Investigations:
DATEINVESTIGATIONS PATIENTSVALUENORMALVALUEREMARKS
OTHERS:

7. XIII.Medication
Date Nameofthe
drug&dose
Route&
frequency
Action Sideeffects Nurses
responsibility
XIV.AntenatalAdvices/HealthEducationOn:
SIGNATUREOFTHESTAFF