Postnatal Assessment

POSTNATAL ASSESSMENT FORMAT

I. History

1. Identification Data:

            Name                                       :

            Age                                         :

            Hospital No                             :

            IP No                                      :

            Marital Status                          :

            Address                                   :

            Father’s / Husband’s Name    :

            Educational Status                  :

            Husband’s Educational Status            :

            Occupation                              :

            Family Income                        :

            Date and time of Admission   :

            Date and Time of Delivery     :

2. Present Obstetric History

            i)  Parity

            ii) Mode of Delivery

·Normal Vaginal

o      With episiotomy         

o      Without episiotomy                                             

o      With tear – First Degree     /   Second Degree  /   Third Degree

·Spontaneous / Medical / Caesarean any other

iii) Full term / Premature

iv) Presentation

      Vertex / Breech / Shoulder / Face

3.  Part Obstetric History:

No	Year	Term / Pre- term still birth / live abortion	Sex	Weight	Remarks
					Complications to Mother & Baby

4. Family history:

    Illness - TB / Hypertension / Diabetes / Asthma / Jaundice

5. Medical / Surgical History:

    Any hospitalization

            Surgeries

            Medical condition

6. Personal History:

o  Dietary

o  Habits

o  Use of contraceptives

7. Menstrual History:

8. Contraception:

9. Psychological:

II. General Physical Examination

     Nourishment          :           Well nourished / undernourished

     Body built              :           Thin / Obese

     Activity                  :           Active / Dull

     Weight                   :           _____________ kgs

     Vital signs              :           Temperature                : ______________ ^oC

                                                Pulse                            : ______________ / mt

                                                Respiration                  : ______________ / mt

                                                Blood pressure            : ______________ mmHg

Mental Status:

Consciousness             :           Conscious / unconscious / delirious

Mood                          :           Anxious / worried / depressed.

Skin Conditions

Colour                         :           Pallor / Jaundice / Cyanosis / Flushing

Texture                        :           Smooth / rough

Moisture                      :           moist / dry

Skin turgor                  :           Hydrated / dehydrated

Temperature                :           warmth / cold / clammy

Lesions                        :           macules / papules / vesicles / wounds

Presence of                  :           spider nevi

                                                Palmar erythema

                                                Superficial varicosities

Hyperpigmentation of :           areola nevi

                                                Linea nigra

                                                Chloasma

Head

Scalp                           :           Cleanliness

                                                Condition of the hair

                                                Dandruff

                                                Pediculi

Face                             :           Pale / flushed / puffiness / fatigue

Eyes

Eyebrows                    :           normal or absent

Eyelashes                    :           infection, sty

Eyelids                                    :           oedema, lesions

Eyeballs                       :           sunken / protruded

Conjunctiva                 :           pale / red / purulent discharge

Sclera                          :           jaundiced

Vision                          :           normal / shortsighted / longsighted

Ear

Hearing                       :           Hearing acuity

                                    :           Any discharges / cerumen obstructing the ear passage

Nose

External hares             :           crust ear discharge

Nostrils                        :           inflammation of the mucus membrane / septal deviations

Mouth & Pharynx

Lips                             :           redness / swelling / crusts / cyanosis / stomatitis

Odour                          :           foul smelling

Teeth                           :           discoloration / dental care

Mucus membrane        :           ulceration / bleeding / swelling / pus formation & gums…

Throat & Pharynx       :           enlarged tonsils / redness / pus

Neck

Lymph nodes              :           enlarged / palpable

Thyroid gland             :           enlarged

Chest:

Thorax                         :           Shape

                                    :           Symmetry of expansion

                                    :           posture

Breath sounds             :           Vesicular sounds

                                    :           Wheezing / Rhonchi

                                    :           Crepitations

                                    :           Pleural rub

Heart                           :           heart rate

                                    :           Location of apex beat

                                    :           Cardiac murmurs

Axilla                          :           any lymph node enlargement

Breast                          :           secreation of colostrums /milk

Engorgement               :           any tenderness / painful

                                    :           tense / dilated veins / warmth / presence of crust

Nipples                        :           retracted / inverted / cracked

Abdomen

Inspection                   :           Presence of scar / wound

                                                If  caesarean : discharge / tenderness

                                    :           presence of striae

Palpation                     :           Height of the

                                                Uterus             :___________ cms

Consistency                 :           hard / firm / boggy

Auscultation                :           Bowel sounds ____________ present / absent

Perineum                     :           clean

Perineum                     :           Intact / tear / wound

Episiotomy                  :           mediolateral / lateral / medial

Condition of the wound:        REEDA: redness / edematous / ecchymosis / discharge / approximation

Lochia

i) Amount of bleeding :          scanty / moderate / heavy

                                    :           No. of beds changed ___________________

ii) Colour                     :           Red / Yellow / White

                                                rubra / serosa / alba.

iii) Odour                    :           Fishy odour / foul smelling

iv) Clots                      :           Present / absent

Cervix                         :           Oedematous / thin / fragile

OS                               :           Open / closed

                                    :           any tear

Vaginal Mucosa          :           smooth / distended / thin / atrophic

Vaginal introitus         :           erythomatous / oedematous

Bladder function         :           amount of urine output _________________ ml

Bowel Function          :

Haemarroids / anal varicosities: present / absent

Ankel oedema / varicose veins

Extremities                  :           Generalized muscular fatigue

Nails                            :           Colour

                                    :           Capillary refill

                                    :           Shape