COMMUNITY HEALTH NURSING –II
ASSIGNMENT
ON
ANTENATAL ASSESSMENT PROFORMA
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Introduction:
Antenatal care is an umbrella term for the care of pregnant women until the child is born and
is aimed at detecting any existing problems that can develop, which could affect the mother
or her unborn baby. Antenatal care (ANC) is the care provided by skilled healthcare
professionals to women throughout their pregnancy. It includes risk identification and
screening, prevention and management of pregnancy-related or concurrent diseases, and
health education and promotion.
Definition:
Systemic supervision (examination and advice) of a woman during pregnancy is called ANC
Aims
To educate the mother about the physiology of pregnancy and labour by
demonstration, charts and diagrams so that fear is removed and psychology is
improved.
To ensure continued risk assessment and to provide ongoing primary preventive
health care.
To prevent or to detect and treat at the earliest any complications.
To screen the high risk cases.
To motivate the couple about the need of family planning and also appropriate advice
to couple seeking medical termination of pregnancy
To discuss the couple about the place, time and mode of delivery, provisionally and
care of the newborn
Objectives
To ensure a normal pregnancy with delivery of a healthy baby from a healthy mother.
Components of antenatal care
Antenatal care comprises of-
Registration of pregnancy
History taking
Antenatal examinations [general and obstetrical]
Laboratory investigations
Health education
ANTENATAL EXAMINATION
CASE NO:
A) IDENTIFICATION DATA
Name of the Client:
Age:
Religion:
Address:
w/o:
Gravida:
Parity:
Living:
Abortion:
LMP:
EDD:
Gestational period:
Registration No./OPD. :
Ward (if admitted):
Under:
Date of Admission:
Provisional Diagnosis (on admission):
Date of Antenatal Assessment:
B) HISTORY TAKING
Social
Type of Family:
Family member:
No of Adults:
No of Child:
Earning Member in the Family:
Total family income per month:
Education: Husband: Wife:
Occupation: Husband: Wife:
Socioeconomic class: Poor/lower middle/upper middle/rich
Type of house: Own/rented
Housing: Kacha/pacca
No. of rooms:
Ventilation:
Sanitation: Sanitary latrine/open field/others
Source of drinking water:
C) PERSONAL HISTORY
Married for:
Habits:
Addiction (Chewing pan/used drug/ tobacco/ smoking/ exposure to smoking/ others):
Allergy:
Infertility treatment:
Contraceptive history:
D) MEDICAL AND SURGICAL HISTORY
Past
Significant (If Significant Specify):
Present
Significant (If Significant Specify)
E) FAMILY HISTORY
Significant (If Significant Specify):
(Twin/diabetes/hypertension/PIH/eclampsia/chromosomal anomalies/hereditary diseases)
Nothing Significant:
F) MENSTRUAL HISTORY
Menarche:
Cycle: Regular/Irregular
Interval:
Duration:
Amount:
Any Problem:
Diet History: Veg/Non-veg
Breakfast:
Lunch:
Dinner:
Remarks:
G) OBSTETRIC HISTORY
No. of Year Abortion Any Mode of Baby Any problem Remarks
Pregnancy (with problems delivery (if (alive/still during
period) during C/S then birth) puerperium
antenatal specify the
period indication)
H) PRESENT OBSTETRICAL HISTORY
Booked/Unbooked:
LMP:
EDD:
Any Problem during:
1st trimester:
2nd trimester:
3rd trimester:
Date/weeks/month of quickening:
Total weight gain till date:
No. of antenatal check up:
Immunization:
Date(1):
(2):
Any iron tablets:
Any other treatment:
I) HISTORY REGARDING PRESENT COMPLAINTS
Physical assessment:
General condition:
Build: Obese/average/thin
Gait/appearance:
Height:
Weight:
Vital Signs:
Blood Pressure:
Temperature:
Pulse:
Respiration:
Head to Toe Examination
Hair and Scalp:
Eyes:
Vision Problem:
Mouth:
Gum:
Dental problem:
Ear:
Nose:
Throat:
Glands:
Extremities:
Breast:
Chest:
Heart:
Liver:
Spleen:
Back and spine:
Legs:
Varicose vein:
J) OBSTETRICAL EXAMINATION
Inspection:
Measurements: SFH in cm: In weeks: Abdominal girth:
Palpation: Fundal grip:
Lateral grip:
First pelvic grip (Leopold’s fourth manoevure):
Second pelvic grip (Pawlick’s grip or third manoevure of Leopold)
Auscultation:
Vulval inspection:(Vulval oedema, any warts/mole/infection/any discharge/bleeding)
Per vaginal examination report (if done):
Pelvic assessment report (if done):
LABORATORY INVESTIGATION:
Blood
Blood for Hb:
Blood Group:
Rh:
VDRL:
HIV:
HbsAg:
Blood for sugar (fasting):
Blood for PPBS:
TORCH(if done):
Stool
Stool-RE/ME:
Urine
Urine for RE/ME:
Urine for sugar:
Albumin:
USG findings:
Any other special investigations:
Observation of high-risk conditions in pregnancy (if present, specify):
Remarks/Impression:
Summary:
