CASE STUDY ON

INTRANATAL MOTHER
DEMOGRAPHIC DATA [ /2M]
Name:________________________________________________________________________________________
Age: __________________________________________________________________________________________
Sex: __________________________________________________________________________________________
D.O.A: ________________________________________________________________________________________
IP No: _________________________________________________________________________________________
Ward: _________________________________________________________________________________________
Bed no: _______________________________________________________________________________________
Marital history: _________________________________________________________________________________
EDD: _________________________________________________________________________________________
GPALS SCORE: ________________________________________________________________________________
Diagnosis: ______________________________________________________________________________________
Surgery: _______________________________________________________________________________________
LMP: _________________________________________________________________________________________
D.O.S: ________________________________________________________________________________________
Address: ______________________________________________________________________________________
Hospital: ______________________________________________________________________________________

History of the patient: [ /18M]

Chief complaints:
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Present illness:
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Past medical history:

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Past surgical history :

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Socioeconomic history :
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Obstetrical &gynaecological history:

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Personal history :
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Menstrual history:
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Dietary history:
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Family history:

Sr. Name of family Age Sex Relation Education Occupation Health

No member with HOF status
1

Family tree:

Marital history:
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Trimester history:
1st Trimester:
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2nd Trimester:
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3rd Trimester:
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PHYSICAL EXAMINATION: [ /7M]

1. General appearance:
Height

Weight

Body built

Look

posture

2. Vital signs:
Temperature

Pulse
B.P
Respiration
Spo2

3. Head to toe examination:

1. Head and neck:
Hair

Scalp

2. Face:
• Eyes:

Eye brow and eye

lashes
Pupils

Conjunctiva

Iris
 • Nose:
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• Ears:
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• Mouth:
Lips

Teeth

Tongue

• Neck :
Thyroid

Range of motion

Throat

3. Chest :

Heart and breath sound: _________________________________________________________________________

• Breast:
Inspection:
Nipple condition: _______________________________________________________________________
Skin changes: __________________________________________________________________________
Palpation:
Any palpable lumps

Evidences of colostrum

Axillarynode enlargement

Engorgement Evident / not evident

Any other significant findings

4. Abdominal examination:
Inspection

Palpation

Consistency

Auscultation

Anything significant

5. Genitalia :
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6. Rectum :
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7. Back and spine :
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8. Perineal examination:
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9. Extremities :

Homans sign Positive/Negative

Edema Evident/Not evident

INTRANATAL EXAMINATION:
Vital signs:
Temperature
Respiration

Pulse

Blood pressure
Spo2
Past obstetrical history:

Sr Year Full Preterm Abortion Types of Sex of Alive Still Weight Remark
no term delivery baby birth

Prenatal visit:

Date of Weight Height Urine B.P FHR Weeks Height Position Treatment
booking of of
gestation fundus
USG finding:
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has been ___________________ hours in labor __________________________ membrane
rupture / intact___________________________hours ago___________________________.
Condition on admission:
General condition: good/average/poor
Hydration: _________________________________________________________________
Anemia: ___________________________________________________________________
Edema: ____________________________________________________________________
Bladder: ___________________________________________________________________
Any other findings: __________________________________________________________
Abdominal examination:
Palpation:
Haight of the uterus in CM _____________________ in weeks _______________________
abdominal girth: _____________________ condition on uterus _______________________
Palpation: __________________________________________________________________
Fundal grip: ________________________________________________________________
Lateral grip: ________________________________________________________________
Pelvic grip: ________________________________________________________________
Pawlic grip: ________________________________________________________________
FSH: ______________________________________________________________________
Presentation: _______________________________________________________________
Position: ___________________________________________________________________
Engagement: _______________________________________________________________
P.V examination:
Date Time Findings
Management during first stage of labor:
Time of onset of labor __________________ time of fulldilation of cervix ______________
walk/rest: __________________________________________________________________
diet: ______________________________________________________________________
bowel: ____________________________________________________________________
bladder: ___________________________________________________________________
Relief of pain: ______________________________________________________________
General care: _______________________________________________________________
Vulval toileting: _____________________________________________________________
Bath: _________________________ clothing: ____________________________________
Encouragement: _____________________________________________________________
Progress notes of labor:
Stages of labor Time of onset Total duration Remark

Stage 1 _____hrs_____min

Stage 2 _____hrs_____min

Stage 3 _____hrs_____min

Preparation of labor:
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time duration: _________________________ hrs _________________________ minutes.

Date and time of delivery: _____________________________________________________

Nature of delivery: normal/forcep/ventus/any other:
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Placenta and membrane:

Spontaneous expulsion/ assisted expulsion/ manual
Removal: complete/ incomplete
Abnormalities: ______________________________________________________________
weight: ________________gm. Length of cord: ________________________________cm.

Condition of new born:

Record of any resuscitation measure done:

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breathing: __________________________________________________________________
sex: ______________________ alive / still birth: __________________________________.

Term/preterm/post term: ______________________________________________________

weight: __________________ gm length: ___________________________________cm.

APGAR score:
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airway:
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circulation:
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any abnormalities:
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DISEASE CONDITION: [ /8M]

INTRODUCTION:
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DEFINITION:
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ETIOLOGY:
In book In patient
SIGN AND SYMPTOMS:
In book In patient
DESCRIPTION (PICTURE/DIAGRAM):
INVESTIGATIONS: [ /4M]
In book In patients

DESCRIPTION (PICTURE/DIAGRAM):
TREATMENT & MANAGEMENT: [ /5M]
Medical management:
In book In patient

Surgical management:
In book In patient

DESCRIPTION (PICTURE/DIAGRAM):
NURSING ASESSMENT: [ /4M]
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NURSING DIAGNOSIS: [ /5M]
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Assessment Diagnosis Goal Planning Implementation Rationale Evaluation

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Assessment Diagnosis Goal Planning Implementation Rationale Evaluation

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Assessment Diagnosis Goal Planning Implementation Rationale Evaluation

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Assessment Diagnosis Goal Planning Implementation Rationale Evaluation

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Assessment Diagnosis Goal Planning Implementation Rationale Evaluation

/2M
NURSE’S NOTES: [ /3M]
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HEALTH EDUCATION: [ /8M]

1._________________________

2.____________________________
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4._________________________

5._________________________
CONCLUSION: [ /2M]
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REFERENCES: [ /3M]
Books:
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Websites:
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Other criteria for scoring:

1 Selection of patient [ /3M]

2 Content [ /3M]

3 Submission on time [ /2M]

4 Knowledge on the subject & topic [ /3M]

Remarks:
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[ /100M]

SIGNATURE OF STUDENT: SIGNATURE OF TEACHER: