POST NATAL ASSESSMENT

TOOL
I. Biographic Data

Name of the Mother: Date:

Age: DOA:
Sex: Hospital:
Marital status: IP. No:
Marrried: Unmarried: Unit:
Widow: Divorced: Ward:
Religion: Bed no:
Nationality: Doctor Name:
Education: Diagnosis:
Occupation: Date of delivery:
Monthly Income: Postnatal day:
Address: Date of discharge:
Duration of hospital stay:
Phone no:
II. Chief Complaints:
1.
2.
3.
4.
5.
III. Present Obstetrical History:
Gravida Parity Period Nature of Delivery Method Outcome of Pregnancy Remarks
Of Full Pre of Sex Alive SB Any
Gestation Term Term Delivery other

1. Prolonged delivery: Yes ___________ no ______________ if yes specify____________

2. Complicated delivery: Yes ____________ no _____________ if yes specify ____________

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 3. puerperium _____________

4. Postpartum haemorrhage: mild _____________ moderate ____________ severe ___________

5. Maternal history of postnatal depression: yes __________ no __________if yes

specify___________

6. Any associated maternal conditions due to pregnancy: yes ___________ no ___________

If yes specify_________: PIH__________ Eclampsia__________ Renal failure _________

Gestational DM _____________
Feeding method breast __________ bottle ___________ postpartum Thyroiditis____________
Family planning YES________ NO __________ if yes specify ______________
Any others YES ___________ NO __________
If yes specify __________
IV. Past Obstetric History:

Period Date Pregnanc Labou Method Puerperi

Delivered Gravid para of of y r of um Child
at a gestatio delive events deliver
n ry y
Birth Age Sex
weight

Any congenital deformities to baby: yes _________ no ____________

If yes specify________________
Any other: yes ___________ no _____________
If yes specify________________
V. Medical history:

Any past or person medical problems:

1. Any child hood illness: yes __________ no ___________

if yes specify: TB ___________ measles_________Mumps_________ Typhoid ______
Rheumatic fever ___________ Rubella _________ Convulsions ___________

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 2. Heart disease: yes ___________ no ____________ if yes specify ___________
3. Breast cancer: Yes ___________ No _____________ if Yes specify ______________
4. Lung disease: Yes ___________ No _____________ if Yes specify ______________
5. Muscles or bone problems: Yes ____________ No ____________ if Yes specify
___________
6. Thyroid problems: Yes ___________ No ___________ if Yes specify ___________
7. Stomach problems: Yes __________ No ____________ if Yes specify ___________
8. Urinary problems: Yes __________ No ____________ if Yes specify_____________
9. Pelvic problems: Yes ____________ No ____________ if Yes specify ____________
10. STD disease: Yes____________ No ______________ if Yes specify ____________
11. Mental illness: Yes ___________ No ______________ if Yes specify ____________
12. Epilepsy: Yes ____________ No ______________ if Yes specify _______________
13. Hypertension: Yes ____________ No _____________ if Yes specify _____________
14. Diabetes mellitus: Yes ____________ No ___________ if Yes specify _____________
15. Tumours of any kind: Yes __________ No _____________ if Yes specify _____________
16. H/o Blood transfusion: Yes __________ No ____________ if Yes specify __________
17. H/o any traumatic injuries: Yes __________ No ___________ if Yes specify __________
18. Any others: Yes ___________ No ___________ if Yes specify ____________
VI. History of previous Hospitalizations:

Date/ Month/ Reason for Treatment Duration of Follow up Out come Remarks
Year admission Hospital stay

VII. Past – Surgical History:

H/o Surgeries: Yes____________ No ______________
If yes specify the surgery ____________ cause ____________ outcome ______________
VIII. Family History:
Consanguineous marriage: Yes _______________ No _____________
Type of family: Joint __________ Nuclear ___________

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 History of familial illness: Yes _________ No ____________
If yes: Diabetic mellitus ___________ Hypertension ___________ TB ___________ Heart
diseases_________ Epilepsy _________ Asthma _________ Any other ___________

Family Tree: - Male

- Female

- Client

- Dead

- Illness

IX. Socio Economic History:

Housing: Kutcha ____________ pacca ____________
Lighting: Adequate ____________ Inadequate ____________
Ventilation: Adequate ___________ Inadequate _____________
Drainage: Open ___________ Closed __________
Living locality: Urban ______________ Urban slum ___________ Rural ___________
Occupation: _____________________
Type of work: Heavy__________ Moderate __________ Sedentary _______ Retired_________
Annual income: _____________ (Total family)
Drinking water source: Well _________ Bore well ______________ Public tap ____________
X. Personal History:
Activities of daily living:
Dependent____________ Independent____________ partially dependent____________
Bathing: Daily: yes __________ no ___________ if yes number of times per day__________
Brushing: number of times__________ Type of dentifrice_______________
Voiding: frequency__________ colour ___________ consistency _____________
If any difficulties specify _____________
Defecations/ Bowel movements: Regular _____________ Irregular ____________
Sleep & rest: usual bed time ________ time of awakening ___________ Hrs of sleep____
Sleep disturbance: yes ___________ no ___________ if yes specify ____________

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 Nature of sleep: sound___________ disturbed _________ insomnia ____________
XI. Personal Habits:
Smoking: yes ____________ no _________
If yes since taken _____________ number of packs per day_______________
Frequently: occasionally _____________ sometimes____________ very often____________

Pan chewing: Yes __________ no ____________ since when _______________

If yes number of pans per day ____________

Frequency: occasionally _____________ sometimes _____________ very often

__________

Tobacco chewing: Yes ____________ no ___________ since when ____________

Frequency: occasionally ____________ sometimes ___________ very often __________

Alcohol consumption: Yes ________ no ___________

If yes type of alcohol ___________ since when ___________

Frequency: occasionally________ sometimes _________ in use of alcohol consumption_______

Drugs abuse: yes ___________ no ____________

If yes number of times per day ________

Duration __________ name of the drug ___________

XII. Dietary History:

Vegetarian ________________ Non vegetarian _________________

Name of the food consumed Mostly Sometimes Occasional Never

Milk & milk products

Fruits
Vegetables & Green leaves
Spices
Eggs & meat products
Coffee
Tea

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 Type of food intake: Rice ___________ Wheat __________ Jowar ___________

Number of times food intake _______________ Appetite ____________

History of any allergies:

Yes ______________ no ___________________

Allergic to Reaction Treatment taken

Food

Drugs

Cosmetics

Pet animals

Others

If yes:

XIII. Menstrual History:

Age at menarche: ____________

Cycle: Regular ___________ irregular __________

Duration: 1-3 days ______ 3-5 days ______ 5-7 days _____ more than 7 days _____

Flow: mild _______ moderate _________ severe _________

Colour: Bright red _______ Red _________ brown _________

Consistency: fluid ________ clots _________ both _________

Frequency: every _________ days

Premenstrual symptoms: Yes _______ no _______

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 If yes: 1.

2.

3.

PHYSICAL EXAMINATION:

General appearance: healthy ___________ ill / sick _____________

Orientation to: Time _______ place __________ person ___________ confused __________

Height ___________ weight ____________

Vital signs: Temp _________ Pulse ________ Rhythm _________ volume __________

Respiration _____________ B.P ______________

Built obese: ____________ Moderate ___________ Economical _____________

Posture: Symmetric _________________ Asymmetric ______________

Level of consciousness: Conscious _________ Drowsy _________ Semiconscious _________

Unconscious ______________

Mood: Pleasant _______ cooperative ________ uncooperative _______ depressed _______

Fearful _______ anxious _____________

State of comfort: comfortable ______distressed _____ alert _____ apathy_______ lethargy ______

Personal Hygiene: appropriate ___________ inappropriate ____________

Appropriate eye to eye contact: yes _________ no ________

INSPECTION:

Hair: thick __________ scanty ____________ alopecia ____________

Skull: symmetry ____________ asymmetry____________

Scalp: clean __________ dirty __________ dandruff________ pediculi__________ nits________

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Face: normal ___________ pallor _________ flushed ________ cyanosed _________
symmetrical___________ Asymmetrical ____________

Eyes: symmetry _________ asymmetry ___________

Eye brows: normal __________ equal alignment ___________ unequal alignment ___________
Conjunctiva : normal _________ red ___________ pale __________ purulent __________
Pupils: Reaction to light: right _______mm left ________mm, PERLA yes _______ no _______

Lens: normal _________ opaque ____________

Alteration in vision: yes ________ no ________ if yes specify _____________
Ears: Symmetrical ____________ asymmetrical _______________
Discharge: yes ___________ no _____________
Hearing difficulty: yes _________ no __________
If yes specify: Right ear __________ left ear _________ both ears_________
Nose: normal _________ septal deviation ____________
Mouth: normal __________ left lip __________
Gums: pink _______ bleeding ________ swollen _________
Lips: pink ________ pale ________ day ______ odour _______ angular stomatitis______
Tongue: pink ________ coated ________ pale _________
Neck: lymph nodes: normal ________ enlarged __________
Thyroid gland: normal _______ enlarged __________
Jugular venous distension: present ________ absent _________
Chest: symmetrical ___________ asymmetrical ______________
Shape: normal _________ barrel chest _________ pigeon chest __________ funnel chest
_______ kyphoscoliosis__________
Breast: symmetrical _______ Asymmetrical ________ tenderness ________ masses_______
Breast enlargement: yes ________ no _________
Nipples: normal ________ inverted _________ retracted _________ cracked _________
Soreness of nipple: yes __________ no ___________
Any usual discharge: yes __________ no __________ if yes specify _________
Breast feeding techniques: following __________ not following __________

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Percussion: dullness _____________ resonance __________ Hyper resonance _________
Auscultation: lungs: normal breath sounds________ crepitus _______ wheeze _________
Heart: S1 _________ S2_________ murmurs__________

ABDOMEN:
Inspection: Shape ________ contour _________
Scars: yes ________ no __________ if yes specify _________
Striae ___________
Incisional wound: yes ________ no __________

Types of incision: vertical _________ transverse ___________

Sutures: intact ________ not intact _________

Wound dehiscence: yes _________ no _________ if yes, colour ________ consistency _________

Any discharge: yes _______ no _________ if yes colour _______ consistency______

Ascites: yes __________ no __________

Auscultation: bowel sounds: regular ________ irregular ________ absent _________

Palpation: Involution of uterus __________ fundal height __________

Tenderness: yes ________ no __________

Masses: yes_________ no __________

Mobile ________ immobile _________ size ________ location _______ any other specify _______

Percussion: Dullness__________ Tympani ___________

Upper Extremities: symmetry_________ asymmetry_________ deformity __________

Tremors ___________ contractures ___________
Edema: Present _________ absent ___________

If present: pitting edema ___________ not pitting edema _________

Nails: normal ________ spoon shaped _________ cyanosis _________ pallor _________

Brittleness of nails _________

Capillary refill time: <3 sec___________ > 3sec ___________

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Lower extremities: symmetry _____________ asymmetry ___________

Edema: present___________ absent __________

If present: pitting edema __________ non pitting edema _________ Grade __________

Varicose veins: yes ___________ no ____________

Homan’s sign _________

Patellar reflexes __________

GENITALIA:
Vulva: normal ___________ swelling ___________ tender ___________
Lochia: colour: rubra __________ serosa _________ alba __________ any other ___________
Odour: _______ amount __________ consistency ___________
Frequency of diaper change: _____________ per day
Episiotomy: yes __________ no _________ type _________ healthy __________
Signs of infection: yes __________ no _____________
If yes specify: ___________ colour __________ amount ____________ consistency ___________
Anal sphincter tone: Good ___________ flaccid ____________
MEDICAL EXAMINATION:

Laboratory & radiological investigations:

Sl.No. Test performed Client values Normal values

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Inferences:

Nursing Diagnosis:

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