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Postnatal assessment

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postnatal mother Assessment

Publicado en: Atención sanitaria
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Postnatal assessment

  1. 1. POSTNATAL - ASSESSMENT INTRODUCTION: DEFINITION: OBECTIVES:
  2. 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. 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. 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. 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. 6. VITAL SIGNS: Temperature- Pulse rate- Respiratory rate- Blood pressure- HEAD TO FOOT ASSESSMENT: Head: Face: Eyes: Ears: Nose: Mouth: Neck: Chest: Back:
  7. 7. OBSTETRICAL EXAMINATION: Breast- Uterus- Genitalia: Assessmentof Lochia: Odour - Amount- Colour- Duration- Extremities: Upper extremities- Lower extremities-
  8. 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. 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-

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