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    Antenatal History Format

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    Bincy Jilo
    This document contains an antenatal history format which includes sections on patient profile, reason for hospitalization, menstrual history, obstetric history, family history, medical-surgical history, nutrition, partner's health history, psycho-social history, antenatal examination, investigations, medications, nursing diagnosis, and health education.

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    © All Rights Reserved
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    Antenatal History Format

    Uploaded by

    Bincy Jilo
    13K views9 pages
    This document contains an antenatal history format which includes sections on patient profile, reason for hospitalization, menstrual history, obstetric history, family history, medical-surgical history, nutrition, partner's health history, psycho-social history, antenatal examination, investigations, medications, nursing diagnosis, and health education.

    Original Description:

    obg practical record

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    This document contains an antenatal history format which includes sections on patient profile, reason for hospitalization, menstrual history, obstetric history, family history, medical-surgical history, nutrition, partner's health history, psycho-social history, antenatal examination, investigations, medications, nursing diagnosis, and health education.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    13K views9 pages

    Antenatal History Format

    Uploaded by

    Bincy Jilo
    This document contains an antenatal history format which includes sections on patient profile, reason for hospitalization, menstrual history, obstetric history, family history, medical-surgical history, nutrition, partner's health history, psycho-social history, antenatal examination, investigations, medications, nursing diagnosis, and health education.

    Copyright:

    © All Rights Reserved
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    ANTENATAL HISTORY FORMAT I. Patient profile Full name Age (in years) Hospital No. I. P. No.

    Marital status Education status Occupation Husbands name Age (in years) Education status Occupation Type of family Per capita income Date of booking Date of last antenatal visit Date of admission Obstetric score Gravida Para Abortion Living Still born II. Reason for hospitalization / Chief complaints Onset

    : : : : : Married / unmarried/ divorced/ separated : : : : : : : : : : :

    Duration Severity Relieving factors Aggravating factors

    III. Menstrual history : Age at menarche

    Duration of cycles

    Regularity Flow - heavy/moderate scanty - clots - no. of days

    Any dysmenorrhoea Relief measures Last menstrual period Period menstrual period

    IV. Obstetric history: Present Obstetric history Is pregnancy confirmed :


    Yes / No

    When, where and how it was confirmed What test was done for confirmation Quickening Immunization Any more disorders like :

    Vomiting, haemorrhoids, heart burn, backache, bleeding, varicose vein, constipation, leg cramps, fever, leucorrhoea, anorexia, insomnia, other complaints.

    Past Obstetric History

    Sl No

    Date of delivery

    Place of birth

    Duration of pregnancy

    Method of delivery

    Course of pregnancy

    Labor

    Puerperium

    Baby Sex Wt.

    V. Family History: Congenital diseases Any hereditary diseases Multiple pregnancy Diabetes Heart disease Any mental retardation Hypertension or PIH (in mother/ sisters) Twin pregnancy If yes, In whom ? Mother / Father ? VI. Medical-Surgical History: Child hood disease Chronic disease like asthma, diabetes, epilepsy Previous surgery Injuries especially of back and pelvis Hepatitis, STD, HIV History of anemia Any medication taken at present or past Reason for use, date stopped Blood transfusion, allergic reaction VII. Nutrition: General nutrition veg / non-veg Appetite decreased/increased

    Any eating disorders

    VIII. Partners Health History: Genetic abnormalities Chronic diseases Infections Use of drugs such as cocaine alcohol Smoking habits : tobacco, cigarette Sexually transmitted diseases HIV/ AIDS Blood type IX. Psycho-social history: Emotional changes experienced Womens and familys reactions to present pregnancy Family support system Family members and friends Coping strategies Life style change Social relationships with the neighbours Financial support ANTENATAL EXAMINATION General Appearance Nourishment Body built Height Weight Vital signs : : : : : : Temp : Pulse : Respiration : B.P.

    Mental status : Head to foot examination : Skin turgor: Moisture : Warmth / Temp : Face: Facial puffiness: Lips: Cyanosis, dryness Eyes: Peri-orbital oedema: Conjunctive : Pallor Mouth:

    Tongue: Chest: Thorax : : : : : : : : : : : : :

    Moisture

    Breath sounds

    Heart Axilla Breast

    Shape Symmetry of expansion posture Vesicular sounds Wheezing / Rhonchi Crepitations Pleural rub heart rate Location of apex beat/ Cardiac murmurs any lymph node enlargement any tenderness / painful tense / dilated veins / warmth / presence of crust retracted / inverted / cracked

    Nipples Abdomen Inspection :


    Size, shape, contour, flanks, umbilicus, foetal movements, skin changes,

    Contractions present/not Palpation: - Fundal palpation: Inference : Lie Presentation - Lateral Palpation: Left side Right side Inference: Position Pelvic palpation : - First pelvic grip :

    Inference : Presentation Engagement / not engaged Attitude - Pawlick Grip: Fixed/ Mobile

    Auscultation :

    - FHR - rhythm - location

    Extrimities : Ankle oedema : Capillary refill : Cyanosis :

    INVESTIGATIONS Sl.no. Investigations Patients value Normal value Inference

    USG :

    MEDICATIONS Sl.no name Dose Freq. Route Side effects Nurses responsibilities

    NURSING DIAGNOSIS

    Sl. no Nursing diagn. objective Planning & intrvention Implementation Evaluation

    assessment

    HEALTH EDUCATION Diet

    Exercise

    Hygiene

    Immunization

    Follow - up

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