ANTENATAL ASSESSMENT TOOL

I. BIOGRAPHIC DATA:

Name: DOA:

Age: Ward:

Religion: Bed no:

Nationality: Diagnosis:

Education: Obstetrical score:

G-P-L-A-D

Occupation: L.M.P:

Marital status:

Marital life: E.D.D:

Husband name:

Age:

Education:

Occupation:

Income:

Address:

II. CHIEF COMPLAINTS:

LMP:

EDD:

Period of gestational age:

Date of first booking:

No of antenatal visits:

Any history of minor ailments:

A] First trimester

Nausea---------------

Vomiting------------

Constipation--------------

Giddiness---------------------

Heart Burn--------------------

Burning Micturition-----------------

Pica--------------------

Infections-------------

Leucorrhea------------------

Use of drugs-----------------

Immunization----------------
 B] Second Trimester

Quickening--------------------

Burning Micturition--------------

Pedal Edema--------------------

Back Pain-----------------

Puffiness of Faces----------------

Heart Burn-----------------------

Insomnia-------------------------

Vaginal Discharge------------------

C] Third Trimester

Back pain: ------------------

Pedal Edema-------------------

Abnormalities----------------

IV. PAST OBSTERICAL HISTORY

S.n Gravid Gest- Abnormal Mode Abnorma Aliv Sex Bir Healt Breas
o a ationa ity-ties in Of lities in e th h t
/parity l Pregnanc deliver labour Wt statu feedi
age y-y y s ng
V. PAST HEALTH HISTORY

General Health status: healthy: ---------------------------

Specific Healthy problems---------------------

Previous Hospitalization: Reason: ---------------- Duration: --------------

Treatment: ------------- Fallow Up: ------------------

Surgical History; ----------------------

Allergic History: -------------------------

Accidents: -------------------

VI. ANTENATAL CHECKUPS

Regular: --------------------- Irregular: ------------------

Health services utility: Government: ---------------- Private------------

No of check Up: -------------------

T.T Injections: taken -------------------- Not Taken --------------------

First dose on: ------------ In the month --------------------

By whom -----------------------

Other Immunization --------------------

Second Dose: on -------------- in the month of ---------------

Other immunization ----------------------

VIII. MENSTRUAL HISTORY

Age at Menarche: -------------------

Menstrual cycle: Regular: ------------- Irregular: --------------

Duration of Bleeding: ----------------

Amount of flow: -----------------------

Dysmenorrhea ----------------------

Pre-Menstrual Syndrome: ---------------------

White Discharge: -------------------

IX. PRESENT MEDICAL HISTORY & PAST MEDICAL HISTORY :

Yes--------------------

No--------------------------

Treatment---------------------

Hospitalization-----------------

Fallow up------------------------
 X. PAST SURGICAL HISTORY:

Yes-------------------------

NO---------------------------

Treatment-----------------------

Hospitalization-----------------

Fallow up------------------------

XI. FAMILY HISTORY:

Type of Family: -----------------

No. of Family Members: -------------------

S.no Name of Relation Sex Age Education occupation Health Handicaped If any
Family To head status Disease
Members cause

FAMILY TREE:
XII. HOME ENVIRONMENT:

Type of House: ------------------ No of Rooms

No of Doors: ---------- No of Windows: --------------

No of ventilation: ------------------- Ventilators: ------------

Lighting: -----------------

Water supply: --------------------

Type of Waste Disposal: ------------------

Type of Latrine: ---------------

House: own: ---------------- Rent: -----------------

XIII. SOCIOECONOMIC STATUS OF FAMILY:

Income per Month: ---------------

Family Expenditure: Food: --------- Shelter: --------------

Health: -------------- Recreation: --------------- others ------------

Savings -----------------

XIV. PERSONAL HISTORY

Hygiene: -------------

Dental care: Frequency ------------ Denitrifies --------------

Bath: Frequency ------------------ Material for bath ------------

Elimination: ---------------

Urination: Frequency: ------------- problems-----------

Defecation: Frequency: ----------- Constipation: ---------------

Total hours: --------------- insomnia: -----------

Habits --------------

Smoking: ------------- alcoholism: -------------

Pan chewing: --------------- tea: ------------

Any other specifics: -------------------------

XV. NUTRITIONAL ASSESSENT:

Type of food: vegetarian: ----- non vegetarian: ---- mixed: -------

Staple food: --------------

Meal pattern: -------------

Food beliefs: -------------

Type of food avoided: -------------

24hrs recall:

Total intake by the mother: -------------

Recommended calorie intake: ---------

Food allergies: -------------

Nutritional problems: ------------

Water intake per day: -------liters

General appearances: ----------------

Body built: moderate/obese/thin

Activity: dull/active

Height: ------------- weight: -------------

BMI:

Edema: generalized/localized

Vital signs:

Temperature: ------------

Pulse: ----------------

Respiration: ----------------

Blood pressure: ---------------

Skin:

Colour:

Texture: dry/moist

Head:

Scalp: dandruff/healthy

Hair: bald/evenly distributed

Eyes:

Symmetrical: yes/no

Eyelashes: infectious /healthy

Eyelids:

Conjunctiva: pale/pink
Discharges:

Squint: yes/no

Ears:

Symmetrical: yes/no

Hearing: yes/no

Any discharge: yes/no

Nose:

Nasal septum: deviated/normal

Nostrils: symmetrical/asymmetrical

Discharges: yes/no

Mouth:

Gums: -----------------

Teeth: ---------------

Tongue: ----------------

Lips: -------------------

Odour: ---------------

Neck: -------------

Tonsils: ----------------

Thyroid: enlarged/normal

Lymph node: enlarged/normal

Trachea: --------------

Range of motion:
Chest:

Shape: --------------- movements: ------------------

Heart sounds: -----------

Breath sounds: --------------- abnormalities: ---------------

Breast: symmetry --------------- size: --------------

Skin tenderness ---------------

Nipple: Normal: ---------------- Inverted: ---------------

Extremities:

Upper limbs: range of motion----------

Polydactyl: yes/no

Amputations:

Any other specifics:

Lower limbs: Range of motion---------

Polydactyl: yes/no

Amputations:

Any other specifics:

OBSTETRICAL EXAMINATION

BREAST:

Nipples:

Retracted: ------------ cracked: ----------- ulcers: ----------

Rashes: ---------------------- discharges: --------------

Primary areola: ------------ secondary areola: ----------

Colostrum: ------ started at: -----------

Tenderness: yes/no

Montgomery’s tubercles: Present/Absent

ABDOMEN:

INSPECTION

Skin colour --------------

Shape: --------------

Size: ----------

Pigmentation: Lineanigra -------------

Striae gravidarum: -------

Umbilicus: positions: -----------------

Abdominal girth: -----------

Fundal height: --------------

Visible fetal movements:

Operational scars:

PALPATION:

Fundal palpation: ----------------

Lateral palpation:

Left: -----------------

Right: -------------------

Pelvic palpation: -------------

Second pelvic grip: ------------

AUSCULTATION:

Fetal heart sounds:

Location:------------

Rate: ----------

Abnormal sounds: -------------

Results: ------------

GENITALIA:

Mons pubis: labiamajora: ------------ labia minora: -----------

Warts: ------------- pigmentation: --------------

Vulva: ---------------- External urethral meatus: ------------

Hymen: -----------------

Perineum: ----------------

Rectum and Anus: ------------- Anal Fissures------------- Haemorroids------------

Any discharge: yes/no:

Vaginal examination:

Cervix: Firm: -------- Soft: -------- Hard: ---------

Chadwick sign: ----------------

Osiander’s sign: --------------------

Perineum: Intact: ----------- Tear: ------ Scar: ------------

INVESTIGATIONS:

Blood group:
HIV: positive/negative

HbsAg: positive/negative

Hcv: positive/negative

Any other specific:

TREATMENT:

NURSING DIAGNOSIS:

NURSING CARE PLAN:

HEALTH EDUCATION: