HIGH RISK ANTENATAL ASSESSMENT

GENERAL HISTORY:
NAME OF THE MOTHER: AGE:
OCCUPATION :
ADDRESS :
OBSTETRICAL SCORE:
FAMILY HISTRY:

MEDICAL HISTRORY:

OBSTERICAL HISTORY:

MENSTRUAL HISTORY:

A) HIGH RISK ASSESSMENT DURING ANTENATAL PERIOD:

a) Ectopic pregnancy
b) Antepartum hemorrhage
 Abruptio placenta
 Placenta previa
c) Hyperemesis gravidarum
d) Pregnancy induced hypertension
 Pre eclamcia
 Eclamcia
e) Multiple pregnancy
 f) Hydatidform mole
g) Small for gestational age
h) Hydraminias
 Poly hydraminias
 Oligo hydraminias
i) Gestational diabetes
j) Rh factor
k) Thyroid disorder
l) Intrauterine growth retardation
m) Age
 Elder
 Younger
n) Sexually transmitted disease
o) Tuberculosis
p) Cardiac disease
q) Anaemia
r) Asthma
B) EMOTIONAL RESPONSE DURING PREGNANCY:
a) Feeling about pregnancy

b) Fathers and sibling adjustment

c) Anxious about birth and parenting role

C) EDUCATION ABOUT PREGNANCY BIRTH AND PARENTING:

HISTORY OF PRESENT PREGNANCY:

LMP: EDD:

GESTATIONAL AGE:

VITAL SIGNS:

TEM: PULSE: RESPIRATION: BP:

GENERAL PHYSICAL ASSESSMENT:

HEIGHT: WEIGHT:

HEAD TO FOOT ASSESSMENT:

SCALP :

FACE :

EYES :

NOSE :

EAR :

MOUTH:

NECK :

BREAST :
LIMBS :

SKIN :

VULVA :

ABDOMINAL EXAMINATION:

INSPECTION:

SIZE OF THE ABDOMEN :

CONTOUR OF THE ABDOMEN:

SKIN CHANGES:

FETAL MOVEMENT:

PALPATION:

FUNDAL HEIGHT:

FUNDAL PALPATION:

LATERAL PALPATION:

PELVIC PALAPATION:

GRIP1:

GRIP2:

ASCULTATION:

FETAL HEART SOUND:

FETAL HEART RATE:

FETAL POSITION:

INVESTIGATION:
HEALTH EDUCATION:

FAMILY PLANNING:
Assessment Nursing Goal Intervention Rationale Implementation Evaluation
Diagnosis
Assessment Nursing Goal Intervention Rationale Implementation Evaluation
Diagnosis
Assessment Nursing Goal Intervention Rationale Implementation Evaluation
Diagnosis
 HIGH RISK NEWBORN ASSESSMENT

IDENTIFICATION DATA:

Name of the baby -

Age -

Sex -

Date of birth -

Birth weight -

HISTORY COLLECTION:

Delivery - singleton/twins/triplet

Diagnosis -

Cord - Normal/ Prolapsed

Condition at birth - Active/ Asphyxiated

Any birth anomalities - Present/ Absent

Treatment at birth -

Apgar score - at 1min at 5min

VITAL SIGNS:

Temperature -

Pulse -

Respiration -

ANTHROPOMETRIC MEASUREMENT:

Weight -

Length -
Head circumference -

Chest circumference -

Abdominal circumference -

PHYSICAL ASSESSMENT:

Activity - Active / Dull

Body built - Thin/ Well built

Skin:

Color - Pale/Pink/Jaundice/Cyanosis

Texture - Smooth/ Dry

Turgor - Normal/ Dry

Vernix caseosa - Present/ Absent

Lanugo - Present / Absent

Edema - Present / Absent

Milia - Present / Absent

Mongolian spot - Present / Absent

Head :

Size - Normal/ Macrocephaly/ Microcephaly

Shape - Normal/ Abnormal

Anterior fontanels - Palpable/ Depressed/ Bulging

Posterior fontanels - Palpable/ Depressed/ Bulging

Caput succedaneum - Present / Absent

Cephalohematoma - Present / Absent

Eyelid - Normal/ Edematous

Irish color -

Sclera - White/ Blue/ Yellow

Red reflex - Present / Absent

Nose :

Patent nostrils - Present / Absent

Nasal discharge - Present / Absent

Nasal septal deviation - Present / Absent

Flaring of nostrils - Present / Absent

Ear :

Symmetry -

Appearance -

Pinna in line with eyes -

Mouth :

Secretions - Present / Absent

Intact lip and palate -

Oral trush - Present / Absent

Neck :

Size - Normal/ Abnormal

Neck webbing - Present / Absent

Chest :

Shape -
Movement - Symmetry/ Asymmetry

Breath sound -

Heart sound -

Abdomen :

Shape - Normal/ Distended

Umbilical cord -

Wharton’s jelly -

Bowel sounds -

Female genitalia:

Labia majora - Normal/ Edematous

Labia minora - Normal/ Abnormal

Vaginal discharge - Present / Absent

Male genitalia:

Urethral opening - Present / Absent

Testis - Descended/ Undescended

Epispadias - Present / Absent

Hypospadias - Present / Absent

Spine :

Spine - Intact/ Abnormal

Spina bifida - Present / Absent

Abnormal curvature - Present / Absent

Extremities :

Shape - Symmetric/ Asymmetric

Nail buds - Pink/ Cynosised

Muscle tone - Normal / Abnormal

Polydactylity - Present / Absent

Syndactylity - Present / Absent

Neuromuscular:

Cry - Weak/ Loud/ High pitched

Lethargic - Present / Absent

Activity - Active and alert/ Drowsy

Reflexes:

 Moro Reflex
 Sucking Reflex
 Rooting Reflex
 Tonic neck Reflex
 Grasp Reflex
 Stepping or Walking Reflex
 Babinski sign
 Glabellar Reflex
 Sneezing Reflex
Assessment Nursing Goal Intervention Rationale Implementation Evaluation
diagnosis