التعليموزارة جامعة الملك فيصل كلية العلوم الطبية التطبيقية Ministry of Education King Faisal University College of Applied Medical Sciences قسم التمريض Department of Nursing ANTENATAL HISTORY TAKING & ASSESSMENT SHEET for NDR 335 2021-2022 *from Jarvis, Carolyn: Physical Examination and Health Assessment Laboratory Manual:7th Edition *from WHO: WHO recommendations on Postnatal care of the mother and newborn 2013 * from KFHH,KSA Nursing Assessment Sheet *full mark- accurate and complete *60% - 1/3 of information is missing *less than 60% -more than 1/3 is missing Demographic Data : Total marks /100 Students Name:_____________________________________ ______________________________ Department or Ward #:__________________________ Client First Name:____________________________ Client's Age:___ Diagnosis:________________ age:_________________ Trimester :___ Date: Gestational Chief Complaint (5 marks - student's marks /5) Vital Signs(5 marks - student's marks /5) T P R BP History of Present Illness (HPI) Pregnancy (10 marks - student's marks /10) G Gravida P pregnancy Delivered Para T Term Labor P Preterm Labor A Abortions L Living Children التعليموزارة جامعة الملك فيصل كلية العلوم الطبية التطبيقية Ministry of Education King Faisal University College of Applied Medical Sciences قسم التمريض Department of Nursing Abdominal Examination(20 marks - student's marks /20): Inspection: • Shape …………………………………………………………… • Multiple pregnancy Single ( ) Twins ( ❖ Skin Pigmentation : ▪ Linea nigra : Hyperpigmentation in Brown colour ▪ Striae gravidarum : purple pigmentation ▪ Striae Albicans :silver pigmentation ▪ Scar of previous operation • ) Palpation: Fundal Height : o o Fetal lie : longitudinal ( ) Oblique ( ) Transverse ( Fetal position : LOA ROA LOP ROP ........................................... • Fetal presentation: Cephalic ( ) Breech ( ) • Engagement of fetal head: yes ( ) No ( ) • Auscultation: 3. Fetal Heart Rate : ……………..beat/min Past Medical History (5 marks - student's marks /5) HTN Other/Details: DM CVD/CAD CVA CA Asthma/COPD GERD Hepatitis Osteoporosis Arthritis Seizure Disorder Renal Disease Thyroid Disease Bleeding Disorder Infectious Diseases Breast Disease Anemia Transfusions ) others Ministry of Education King Faisal University College of Applied Medical Sciences Department of Nursing التعليموزارة جامعة الملك فيصل كلية العلوم الطبية التطبيقية قسم التمريض Psychiatric Childhood Illnesses Past Surgical History/ Trauma/ Hospitalization/Visit (5 marks - student's marks /5) Inpatient Surgical Procedure/Date:_________________________________________________________________ Outpatient Surgical Procedure/Date :_______________________________________________________________ Allergies (5 marks - student's marks /5) Drugs:___________________________________________ Foods:___________________________________________ Environment : ______________________________________ Latex: _____________________________ IV Contrast _________________________ Medications and Drug Card (20 marks - student's marks /20) Current/ Recent Prescription Medications:_________________________________________________________________ Current/Recent Over the Counter Medications:_____________________________________________________________ Current/ Recent Herbal/Alternative Medications:___________________________________________________________ Others MEDICATION CARD : Reproductive History (05 marks - student's marks /05) Menstrual: Age at Menarche:_______ LMP: ___________ Estimated date of delivery (EDD): ___________ Fundal height: Complications During previous pregnancy : yes ( ) No ( ) Contraceptives used previous : OCP /name : _____________________________________________________________ IUD Injection/ Frequency : _____________________________________________________ Rhythm Others: _________________________________________________________________ Procedures Undergone : Mammogram/ date : _______________________ Pap smear/ latest date: _____________________ Ministry of Education King Faisal University College of Applied Medical Sciences Department of Nursing التعليموزارة جامعة الملك فيصل كلية العلوم الطبية التطبيقية قسم التمريض Immunization: Diphtheria-Tetanus doses ________ date:________________________ STD History :____________________________________________________________________ Concerns: Family History (5 marks - student's marks /5) Family History Unknown Consanguinity Multiple Pregancy Diabetes Induced Genetic Abnormalities Communicable Diseases Personal/Social History (5 marks - student's marks /5) General: ___fever ___ chills ___ night sweats___ fatigue____ unexplained weight loss___ weight gain Skin: ___Pruritus___ Rash___ Hair Loss___ Worrisome Lesion___ Pigment Change___ Moles___ Sweating___ Dry Skin___ Nail Change HEENT: ___ headache___ dizziness___ earache___ hearing loss___ tinnitus___ vision change___ eye oain/ sensitivity___ excessive tearing___ eyeglasses/contact use___ glaucoma___ rhinorrhea___ nasal congestion___ postnasal drip____ sinus pain___ nosebleeds___ hay fever____ sore throat___ mouth sores___ hoarseness____ toothache____ bleeding gums___ dentures Breast: ___ pain___ lumps___ discharge___ enlargement___ tingling____ fullness Pulmonary: ___ cough___ sputum___ hemoptysis___ SOB___ pain with respiration___ wheezing___ cyanosis CV:___ Chest pain___ Palpitations___ DOE___ Orthopnea___ PND___ Diaphoresis___ Syncope___ Heart Murmur___ Leg edema___ anemia___ bleeding PVD: ___Claudication___ varicose vein___ phlebitis___ coldness of hands/feet___ Leg Ulcers GI:___ dysphagia___ heartburn___ change in appetite___ Food intolerance___ nausea___ vomiting___ hematemesis___ abdominal pain___ bloating___ flatulence___ diarrhea___ constipation___ melena___ jaundice___ dark urine___ BRBPR___ change in BM___ hemorrhoids___ hernia GU:___ dysuria___ urgency___ frequency___ hematuria___nocturia___ polyuria___ suprapubic pain___ flank pain___ incontinence___ lesions____ vaginal itch___ abnormal vaginal discharge___ vaginal dryness___ dyspareunia___ sexual dysfunction___ abnormal vaginal bleeding Endocrine:___ polyuria___ polydipsia___ polyphagia___ heat/cold intolerance___ tremor___ lump in throat___ unexplained weight change___hair changes MSK: ___ joint pain ( location____________________) ___ stiffness___ restriction of motion___ swelling___ erythema___ wadding gait___ myalgia___ muscle cramps___ weakness___ antalgic gait___ back pain التعليموزارة جامعة الملك فيصل كلية العلوم الطبية التطبيقية Ministry of Education King Faisal University College of Applied Medical Sciences قسم التمريض Department of Nursing Psych: ___anxiety___ panic attacks___ depression___ mood changes___ irritability___ nervousness___ eating disorder___ sleep disturbance___ PRESENT OBSTETRICAL HISTORY (5 marks - student's marks /5) Date of Admission :Antenatal visits : Date of visit Weeks of pregnancy Weight Position Presentation Lie FHR Remarks if any Functional Assessment (5 marks - student's marks /5) SELF-ESTEEM, SELF CONCEPT ________________________________________________________________________ II. ACTIVITY/ EXERCISE _________________________________________________________________________________ III. SLEEP/REST ____________________________________________________________________________ IV. NUTRITION/ELIMINATION __________________________________________________________________________ I. التعليموزارة جامعة الملك فيصل كلية العلوم الطبية التطبيقية Ministry of Education King Faisal University College of Applied Medical Sciences قسم التمريض Department of Nursing NURSING CARE PLAN FORMAT AND MARKING CRITERIA(NDR 3101335 Provider of Care II: Child Bearing & Child Rearing Family Health) Name of Student:______________ Date Submitted: ________________________Grade: ___ /100 PATIENT’S DATA Patient's Name: Age: Department: Date of Admission: Confirmed Diagnosis: _______________________________________ SIGNATURE OVER PRINTED NAME OF EVALUATOR/ DATE Assessment Nursing Diagnosis Includes correct and complete Subjective and Objective data 20 points Identifies ONE specific nursing diagnosis (in Problem-Etiology format) based on nursing assessment 15 points Patient’s Goal (s) Identifies ONE goal for each nursing diagnosis 15 points Nursing Interventions Includes at least FIVE nursing interventions planned for each nursing diagnosis 30 points Rationale Evaluation States the correct/ appropriate rationale per nursing intervention. 15 points Includes the outcomes of the nursing intervention for each nursing problem including the indicators for goal achievement 5 points : التعليموزارة جامعة الملك فيصل كلية العلوم الطبية التطبيقية Ministry of Education King Faisal University College of Applied Medical Sciences قسم التمريض Department of Nursing Health education ( 5 marks - student's marks /5) Mother's need Nursing health education Health promotion Breast care Hygiene Rest and sleep Exercise Nutrition Daily Fetal Movement Count Regular Follow up Relief measures for common discomforts of pregnancy Preparation for parenting: Appropriate preparation Mother response