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    Intranatal Assessment Kempegowda College of Nursing, V.V.Puram, B'Lore-04

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    Vijith.V.kumar
    This document contains an intranatal assessment form that collects information about a patient's pregnancy. It includes sections to document the patient's baseline data, antenatal history, family history, socioeconomic background, past medical and obstetric history, examination findings, and details of labor and delivery. The form is used to comprehensively assess and document the course of a patient's pregnancy, childbirth, and immediate postpartum period.

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    Intranatal Assessment Kempegowda College of Nursing, V.V.Puram, B'Lore-04

    Uploaded by

    Vijith.V.kumar
    2K views8 pages
    This document contains an intranatal assessment form that collects information about a patient's pregnancy. It includes sections to document the patient's baseline data, antenatal history, family history, socioeconomic background, past medical and obstetric history, examination findings, and details of labor and delivery. The form is used to comprehensively assess and document the course of a patient's pregnancy, childbirth, and immediate postpartum period.

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    INTRANATAL ASSESSMENT.docx

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    This document contains an intranatal assessment form that collects information about a patient's pregnancy. It includes sections to document the patient's baseline data, antenatal history, family history, socioeconomic background, past medical and obstetric history, examination findings, and details of labor and delivery. The form is used to comprehensively assess and document the course of a patient's pregnancy, childbirth, and immediate postpartum period.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    2K views8 pages

    Intranatal Assessment Kempegowda College of Nursing, V.V.Puram, B'Lore-04

    Uploaded by

    Vijith.V.kumar
    This document contains an intranatal assessment form that collects information about a patient's pregnancy. It includes sections to document the patient's baseline data, antenatal history, family history, socioeconomic background, past medical and obstetric history, examination findings, and details of labor and delivery. The form is used to comprehensively assess and document the course of a patient's pregnancy, childbirth, and immediate postpartum period.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 8

    INTRANATAL ASSESSMENT KEMPEGOWDA COLLEGE OF NURSING, V.V.

    PURAM, BLORE-04 INTRODUCTION

    BASELINE DATA Name Age Ip.no Education Occupation Date of admission Religion Mother tongue Monthly income LMP EDD Obstetrical score : : : : : : : : : : : :

    ANTENATAL HISTORY First trimester

    Second trimester

    Third trimester

    FAMILY HISTORY Type of family No of working members Any chronic disease/hereditary diseases

    FAMILY TREE

    SOCIO ECONOMIC BACKGROUND Ability to afford hospital expenses: Financial assistance :

    PAST MEDICAL OR SURGICAL HISTORY

    MENSTRUAL HISTORY Age of menarche Menstruation Flow Frequency Duration : Regular / Irregular :Mild/ Moderate/ Severe : :

    MARITAL HISTORY Duration of married life : Type of marriage :Consanguineous/ Non consanguineous

    PAST OBSTETRIC HISTORY


    SINO DT/YEAR OF DELIVERY PLACE OF BIRTH DURATION OF PREGNANCY METHOD OF DELIVERY PUERPERIUM SEX AND WEIGHT REMARK

    PERSONAL HISTORY Diet :vegetarian/ Mixed Sleep pattern Appetite Bowel and bladder pattern Habits Exercises

    HEAD TO FOOT EXAMINATION


    GENERAL OBSERVATION: Appearance Body built Orientation State of Nutrition: Cooperativeness:

    MEASUREMENTS Height Weight Weight gained during pregnancy

    TEMPERATURE Si no 1 2 3 4 Vital signs Temperature Pulse Respiration Blood pressure Patients value Normal value Remark

    HEAD TO FOOT ASSESSMENT


    HEAD FACE Facial puffiness Cholasma EYES EARS NOSE Appearance : Discharge : Patency : Appearance : Discharge: Hearing : Eye brows and eye lashes Conjunctiva : Sclera : Pupilary reaction: Vision Peri-orbital edema

    MOUTH AND THROAT NECK General appearance : Trachea : Lymph node : Thyroid gland Lips : Tongue : Teeth : Gums : Buccal mucosa: Tonsil:

    CHEST I. Breast

    Inspection Primary and secondary areola : Montgomerys tubercle :

    Palpation : Enlargement of lymph nodule s : Engorgement of breast : Presence of colustrum/ mil :

    Auscultation: Heart rate Respiratory rate Any abnormalities

    ABDOMEN Inspection Size : Shape : Contour : Umbilicus : Linea niagra & striae gravidarum: Fundal height : Fetal movements: Abdominal Scar : Abdominal girth : Palpation : Fundal Palpation:

    Lateral Palpation: Left lateral palpation :

    Right lateral palpation :

    Pelvic Grip:

    Pawlik palpation:

    Auscultation: FHR Location

    P.V FINDINGS Cervical dilatation : Effacement: Station : Liguor: Pelvis :

    DESCRIPTION OF FIRST STAGE :

    DISCRIPTION OF SECOND STAGE:

    DESCRIPTION OF THIRD STAGE :

    LENGTH OF LABOUR 1st stage 2nd stage 3rd stage Total hours

    CONDITION OF MOTHER AFTER DELIVERY Pulse : Blood plessure: Fundal height: Uterus : Vaginal bleeding: Total blood loss:

    CONDITION OF PUERPERIUM Episiotomy type: Type of suturing Material used :

    PLACENTAL DETAILS: Weight Cord length Complete/ incomplete

    CONDITION OF BABY Weight: Cry Apgar score: 1st minute 2nd minute

    DRUGS GIVEN FOR MOTHER sino Drug Dose Route Frequency Action Side effect

    DRUGS GIVEN FOR BABY sino Drug Dose Route Frequency Action Side effect

    NURSING DIAGNOSIS

    HEALTH EDUCATION

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