POSTNATAL
ASSESSMENT
Definition: post
natal assessment of mother includes systemic examination of the mother after
delivery
Purpose:
·
To assess the heatl staus of the mother to institute
effective therapy
·
To detect and to treat the earliest any
gynaecological condition arising durtring the period
·
To note the progress of the bay and to solve the
feeding problem
·
To impart family planning guidance:
Routine examination includes:
·
Weight
checking
·
Checking
vitals
·
Examination of perineum
·
Examination
of breast
·
Examination
and measurement of involution of uterus
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
·
With
episiotomy
·
Without
episiotomy
·
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:
·
Dietary:
·
Habits:
·
Sleep:
·
Use of
contraceptives:
7. Menstrual History:
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 : secretion
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
Extremities : Generalized
muscular fatigue/ Calf muscle pain/ swelling
Ankle Oedema / varicose veins/ backache
Nails : Colour
: Capillary
refill
: Shape
Reporting and recording:
·
Report
the abnormal finding to the mother and to the physician
·
Record
the findings in the post natal chart.
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