GLOBAL COLLEGE OF NURSING

FORMAT FOR POST NATAL ASSESSMENT

I. BASE LINE DATA
 Hospital:

 IP no:

 Name:

 Age:

 Address:

 Religion:

 Language:

 Education:

 Husband:
 Wife:
 Occupation:

 Husband:
 Wife:
 Ward/OPD:

 Obstetric score:

 Gestational age:

 LMP:

 EDD:

 Blood group of patient:

 Date and time of delivery

 Mode of delivery

 Diagnosis:
II.CHIEF COMPLAINTS/REASON FOR ADMISSION

III. OBSTETRICAL HISTORY

A.HISTORY OF PREVIOUS PREGNANCY

B. PRESENT OBSTETRICAL HISTORY

PRESENT PREGNANCY
PRE TERM / FULL TERM
I Trimester

II Trimester

III Trimester

IV.ADMISSION NOTES
 Date of admission:
 Time of onset of Contractions

 Membranes: Intact/Ruptured

 FHR:
 V.POSTNATAL ASSESSMENT

Day 1 Day 2 Day 3

Vitals Temperature
Pulse
Respiration
BP
Breast Nipple
Consistency
Breast feeding
Uterus Fundal height
Consistency
Bowel
Regular/irregular
Constipation
Bladder
Emptied/ not emptied
Lochia Type
Amount
Colour
Episiotomy Type
Pain
REEDA
Redness
Ecchymosis
Edema
Discharge
Wound approximation

Emotional response

Homan’s sign
Positive/negative
Condition of the child
Urine
Meconium
Skin colour
Adequacy of breast feeding

Sleep

VI.DELIVERY NOTES
Date and Time:
Duration
First stage:

Second stage:

Third stage:
 On PV

 Os fully dilated at: Am/pm

 Membranes ruptured at: am/pm

Mode of delivery
 Normal/assisted:

 Episiotomy:

 LSCS

Baby born
 Sex - male/female

 Time - am/pm

 Weight -

 Apgar - at 1st min:

at 5th min:

 Condition – alive/still/macerated/dead

 First passage of urine

 First passage of stool

Placenta

 Delivery at: am/pm

 Weight :

 Length of cord :
  Mode of delivery – CCT/Manual removal of placenta

 Examination of placenta and membranes

Entire/incomplete

Vaginal bleeding -Within normal limits/abnormal

If abnormal - Cause:

VII.PROGRESS NOTES
DATE CONDITION OF MOTHER CONDITION OF CHILD
VIII.POSTNATAL ADVICE
MOTHER
1. Rest and ambulance

2. Diet

3. Care of vulva and episiotomy

4. Breastfeeding and breast care

5. Maternal and infant bonding

6. Personal hygiene

7. Family planning

8. Care of bowel and bladder

9. Immunization
10. Post natal exercises
11. Nutritionalsuplementation and immunization
12. Follow up
BABY
1. Baby care

2. Immunization

3. Top feeding

4. Follow-up

Signature of student Signature of supervisor

 GLOBAL COLLEGE OF NURSING
FORMAT FOR POSTNATAL CAREPLAN
I. BASE LINE DATA
 Hospital:

 IP no:

 Name:

 Age:

 Address:

 Religion:

 Language:

 Education:

 Husband:
 Wife:
 Occupation:

 Husband:
 Wife:
 Ward/OPD:

 Obstetric score:

 Gestational age:

 LMP:

 EDD:

 Blood group of patient:

 Date and time of delivery

 Mode of delivery

 Diagnosis:
 II.CHIEF COMPLAINTS/REASON FOR ADMISSION

III. OBSTETRICAL HISTORY

A.HISTORY OF PREVIOUS PREGNANCY

N Ye Fu Prete Abort Type of Nature Nature Child

o: ar ll rm ion delivery of of
ter pregna puerpe
m ncy rium
Aliv Still Sex Birth
e birth wt

B.PRESENT OBSTETRICAL HISTORY

1st Trimester
 Confirmation of pregnancy at ______ weeks of gestation.

 Confirmation is by ________ test.

 Medications with dose

 Complaints during first trimester

 H/O bleeding per vagina: Yes/No

 Scan:
2nd Trimester
 Complaints during second trimester

 Quickening felt at: ______ month

 TT immunizations:

 Supplementations with dose:

 Scan:

3rd Trimester
 Complaints during third trimester

 Fetal movements:

 Medications

 Scan

V. HISTORY COLLECTION
Present history
Medical

Surgical

Past history

Medical

Surgical
VI. MENSTRUAL HISTORY:
 Age of menarche:

 Menstrual cycle: Regular/Irregular

 Bleeding: Mild/Moderate/Severe

 Complaints during menstruation:

VII.FAMILY HISTORY:

 Type of family

 No.of members in the family

 H/o consanguineous marriage

 Hereditary illness

 Family genogram:

VIII PARTNER’S HISTORY:

 Age:

 Blood group:

 Habits of smoking/alcohol:

 Habits of doing exercise:

 Attitude towards pregnancy:

IX PERSONAL HISTORY
Nutrition
 Type of diet:

 Appetite:

 Any allergy to food stuffs:

Rest & Sleep
 Duration of sleep at night:

 Hours of rest at day:

Elimination
 Bowel habits:

 Frequency of micturition:

Hygiene

 Personal hygiene:

 Grooming:

Habits

 Exercise
 Alcohol consumption:
 Cigarette smoking:

 Drug abuse:

 Betel leaves:

 Caffeinated drinks:

 Pica:

Allergies:
 Food

 Medications
X .MARITAL HISTORY
 Duration of married life:

 Type of marriage:

 Use of contraceptives

 If yes -specify

 Marital relationship

XI.SOCIO ECONOMIC HISTORY

 Housing

 Ventilation

 Light

 Water supply

XII PHYSICAL EXAMINATION

General Appearance
 Type of built:

 Degree of nourishment:

 Level of consciousness:

Vital signs
 Temperature:
 Pulse:
 Respiration:
 Blood pressure:

Anthropometric measurement
 Height:
 Weight:
 BMI
Skin
 Butterfly mask:
 Linea niagra:
 Striae gravidarum:
 Striae albicans:
 Pallor:
 Jaundice:
 Edema: Face/Feet/Generalized/Nil

Neck
 Thyroid enlargement:
 Tonsillitis:
 Lymph node enlargement:

Mouth
 Lips
 Teeth:Dental caries/Gingivitis:
 Tongue Colour
Coated tongue:
Respiratory system
 Respiratory rate
 Abnormalities

Musculo-Skeletal System
 Gait:
 Vertebral column: Kyphosis/Scoliosis/Lordosis/Normal
 DVT:
Cardiovascular system

 S1 and S2 sounds
 Any abnormalities

Central-Nervous System
 H/O headache, giddiness or irritability:

Upperlimbs
 Capillary refill

 Carpel tunnel syndrome

 Edema

Lower limbs
 Varicosities

 Edema

V.POSTNATAL EXAMINATION
B-Breast
U-uterus
B-Bowel
B-Bladder
L-Lochia
E-Episiotomy
H-Homan’s sign
E-Emotional response
BREAST
Inspection
 Size:
 Symmetry
 Shape:
 Engorgement:
 Primary and secondary areola:
 Montegmory tubercles
 Nipple: erected/ inverted/cracked

Palpation:
 Palpation done by----
 Lymph node
 Colustrum
 Lumps
 Complaints

UTERUS
 Position
 Consistency
 Fundal height

BOWEL
 Bowel sounds
 Constipation

BLADDER
 Time of emptying the bladder
 Distension
LOCHIA
 Odor
 Colour
 Type
 No.of pads/day
 Duration

EPISIOTOMY
 Redness-
 Edema
 Echymosis
 Discharge
 Approximation

HOMAN’S SIGN
EMOTIONAL STATUS

NEWBORN ASSESSMENT
I.BASE LINE DATA
Name of the Baby
Age
Gender
Date of birth
Time of birth
Birth weight
Any problems during birth
APGAR Score
Mode of birth
 II.APGAR SCORE

COMPONENT 0 1 2 1ST 5TH

MINUTE
MINUTE

Heart rate Absent <100 >100

Respiratory Absent Slow Good
rate irregular crying
Muscle tone Flaccid Some Action
flexion of
extremities
Reflexes No Weak Vigorous
response cry/grimace cry

Color Blue Body pink Complete

extremities pink
Pale
blue
TOTAL SCORE

Passage of first stool:

Passage of first urine:
III.ANTHROPOMETRIC MEASUREMENT
Length
Weight
Head circumference
Chest circumference
Abdominal circumference
IV. VITAL SIGNS
Temperature
Heart rate
Respiration
PHYSICAL ASSESSMENT
Head
 Anterior fontanelle
 Posterior fontanelle
 Caput succedenum
 Cerebral edema
 Cephalhematoma

Skin
 Colour
 Lanugo
 Vernix Caseosa
 Skin turgor
 Mongolion spot
Milia

Eyes
 Ophthalmia neonatarum
 Pupillary reaction

Nose
 Nasal septum
 Bleeding
 Discharge

Mouth
 Cleft lip and cleft palate
 Oral thrush
 Epstein reflex
Ears
 Symmetry
 Discharges

Neck
 Lymphnode
 Clavicle

Chest
 Symmetry
 Heart rate
 Heart sounds
 Respiratory rate
 Lungs
Abdomen
Shape
Movement
 Umbilical cord
 Distention
 Bowel sounds

External Genitalia
 Specify any abnormality present
 Male Baby
 Testis : Undescended / descended
 Penis : Foreskin covered / uncovered
 Female baby
 Labia majora
 Discharges
Extremities
 Movements
 Polydactyly or syndactyly
 Nails : Nail beds
 Any anomalies

Back
 Curvature
 Abnormality

Neuromuscular system
 Cry
 Flexion of extremities
 Extension of extremities
 Turns head from side to side

REFELEXES
 Glabellar reflex

 Gag reflex

 Sucking and swallowing reflexes

 Babinski reflex

 Rooting reflex

 Motor reflex

 Blinking reflex

 Parachute reflex
 Palmar grasp reflex

 Plantar grasp reflex

 Dancing reflex

 Tonic neck reflex

XV. DELIVERY DETAILS

 Time of rupture of membranes

 Date of delivery:

 Time of delivery:

 Type of delivery: Spontaneous /Inducecd

 Mode of delivery:

 Total duration of Labour

I stage

II stage

III stage

 Episiotomy

 Any injuries and repair of injuries

 Bleeding

DELIVERY OF THE PLACENTA AND THE MEMBRANES

Placenta delivered at :
Mode of expulsion CCT/Manual :
Examination of the placenta
 Cord Insertion
 Cord length
 Number of cotyledons
 Maternal surface
 Fetal surface
 Weight of the placenta
 Cord abnormalities
 Number of Umbilical blood vessels

PROGRESS NOTES
DATE CONDITION OF THE CONDITION OF THE
MOTHER CHILD

XII INVESTIGATIONS
SL NO INVESTIGATIONS RESULT NORMAL REMARKS
DONE VALUE

Ultrasonography
XIII MEDICATIONS
SLNO DRUG DOSE ROUTE ACTION NURSES
NAME RESPONSIBILITY

XIV NURSING CARE PLAN

MOTHER
BABY

VIII.POSTNATAL ADVICE
MOTHER
13. Rest and ambulance

14. Diet

15. Care of vulva and episiotomy

16. Breastfeeding and breast care

17. Maternal and infant bonding

18. Personal hygiene

19. Family planning

20. Care of bowel and bladder

21. Immunization
22. Post natal exercises
23. Nutritionalsuplementation and immunization
24. Follow up

BABY
5. Baby care

6. Immunization

7. Top feeding

8. Follow-up

Signature of student Signature of supervisor