Post Partum Record (1)

Student name: Munirah Hamad

Student number:
Section:
Date:
History
Day:
1- Personal &social history:
Nora Naser
 Mother Name: -------------
 Age: 32
 Level of Education: …………..
 Marital Condition: …………...
 Degree of relation:……………
2- Menstrual History:
14
 Age of menarche: ----------------------------
 Average interval between period:-------------------------------
&
 Duration: 23
- Rhythm:
3- Medical Surgical History
A) Medical

j
 Diabetic
 *Hypertension:----------
 Others:------------------
 B) Surgical

-
Curettage------------------------------
CS(cesarean section)
 Major operation .--------------------
4- Family History:
 Diabetes 8 : ·
y
 Multiple pregnancy ----------------
 Others &

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12
  5-Obstetrical History:
 Gravida
 Para
22
 Abortion ---------------
-
-
 Stillbirth--------------
 *
Intra Uterine Fetal Death-----------------------
2
 No. of living children :---------

· -2
 No. of low birth weight:------------
 Age of the youngest child
6-Previous deliveries :
previous Mode of Complications Outcome of the

deliveries delivery Pregna

ncy
1. C No
2. CS 10
3.
4.

Current delivery:
 Type of Delivery: LS

 Time and Date of Delivery: 8 : 30 so

 Place of Delivery: ·
&

 Time of initiation of Breast Feeding: 40

Vital Signs:
1. Blood pressure -------------------------- mmhg
o
2. Temperature: C
3. Pulse: b/m
4. respiration: c/m
Uterine condition:
48
& Consistency
E Level e
-

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13
Lochia condition
Type
Color
Odor-------------
Perineal condition:
R:
E:
E:
D:
A:

Wound:
Site: ·i
Condition: &
Breast:
Cholstrum: &
-

Nipple: e
Postpartum complications:-
Neonatal condition
 Sex: female
1 79
by
 Weight: -------------
.

 Length: m
30cm
 Head cirmfernance:-----------
 Chest cirmfernance:-------------
28cm
 Reflexes: Maso ,
suching Swallowing
,

Nursing diagnosis:

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14
 Nursing care plan
Nursing diagnosis Patient outcome Nursing intervention

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15
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