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    ANTENATAL Case Study Format

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    Delphy Varghese
    This document outlines the format for an antenatal care study at Lourdes College of Nursing. It includes 12 sections that will be covered in the study: 1) baseline data about the patient, 2) history of present and past illnesses, 3) antenatal examination, 4) investigations, 5) medications, 6) diet plan, 7) disease aspects, 8) nursing management, 9) daily nurse's progress notes, 10) discharge plan and health education, 11) conclusion, and 12) bibliography. The format collects comprehensive information about the patient's medical history, pregnancy, and care during antenatal visits and admission.

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    ANTENATAL Case Study Format

    Uploaded by

    Delphy Varghese
    11K views4 pages
    This document outlines the format for an antenatal care study at Lourdes College of Nursing. It includes 12 sections that will be covered in the study: 1) baseline data about the patient, 2) history of present and past illnesses, 3) antenatal examination, 4) investigations, 5) medications, 6) diet plan, 7) disease aspects, 8) nursing management, 9) daily nurse's progress notes, 10) discharge plan and health education, 11) conclusion, and 12) bibliography. The format collects comprehensive information about the patient's medical history, pregnancy, and care during antenatal visits and admission.

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    ANTENATAL case study format for nursing student

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    ANTENATAL case study format

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    This document outlines the format for an antenatal care study at Lourdes College of Nursing. It includes 12 sections that will be covered in the study: 1) baseline data about the patient, 2) history of present and past illnesses, 3) antenatal examination, 4) investigations, 5) medications, 6) diet plan, 7) disease aspects, 8) nursing management, 9) daily nurse's progress notes, 10) discharge plan and health education, 11) conclusion, and 12) bibliography. The format collects comprehensive information about the patient's medical history, pregnancy, and care during antenatal visits and admission.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    11K views4 pages

    ANTENATAL Case Study Format

    Uploaded by

    Delphy Varghese
    This document outlines the format for an antenatal care study at Lourdes College of Nursing. It includes 12 sections that will be covered in the study: 1) baseline data about the patient, 2) history of present and past illnesses, 3) antenatal examination, 4) investigations, 5) medications, 6) diet plan, 7) disease aspects, 8) nursing management, 9) daily nurse's progress notes, 10) discharge plan and health education, 11) conclusion, and 12) bibliography. The format collects comprehensive information about the patient's medical history, pregnancy, and care during antenatal visits and admission.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4

    LOURDES COLLEGE OF NURSING – SIDHI SADAN

    ANTENATAL CARE STUDY FORMAT

    Sl.
    CONTENT
    No.
    I BASELINE DATA

     Name
     Age
     I P No.
     Ward
     Marital status
     Religion
     Education
     Occupation
     Obstetrical score
     LMP
     EDD
     Gestational age in weeks
     Date of admission
     Diagnosis
     Date of discharge
    II HISTORY
    1. Present illness history
     Chief complaints for admission
     History of present illness and Management
    2. Past obstetric history:
    OB Score: GPLA

    Year Type of Sex Family


    delivery planning
    Complications if any method
    adopted

    AN IN PN

    3. Present obstetrical history


    I Trimester II Trimester III Trimester
    4. History of antenatal visits

    Date Gestati Urine Minor ailments/


    onal Wt BP FHR Immunization treatment/
    age Alb Sug remarks

    5. Past health history


     Illness
     Treatment
     Medications / surgery
     Other managements
    6. Menstrual history
     Age of onset of menarchae
     Cycles - regular/ irregular(no: of days / frequency of cycle)
     Any discomfort associated with menstruation
    7. Personal history
     Nutrition
     Habits
     Elimination
     Exercise
     Rest and sleep
    8. Family history
     Type : Joint/ Nuclear/extended
     No. of members
     Support person
     Any illness – TB, DM, HT, Heredity etc.( related to present condition of the
    mother)
    9. Environmental history
     Health care facility
     Housing
     Water
     Drainage
    10. Socio-economic and cultural background
     Social class
     Family income
     Relationship with family members & neighbours
     Any specific customs
     Food habits
    11. Mental and emotional status
    III ANTENATAL EXAMINATION
    a. Physical examination
     Body built
     Height
     Weight
     Posture
     Gait
     Grooming
     Vital signs : Temperature, Pulse, Respiration, B.P
     Head, Eyes, Ear, Face, Nose, Mouth, Neck, Lymphnodes
     Breast
     Respiratory system
     Cardiovascular system
     GI system
     Genitourinary system
     Musculoskeletal system
     Integumentary system
     Central nervous system
    b. Abdominal examination
    a. Inspection
     Size  Skin changes  Umbilicus
     Shape  Bladder  Flanks
     Contour  Fetal movements  Any other

    b. Palpation
    i. Abdominal girth
    Height of fundus
    in weeks
    in centimetres
    ii. Lateral palpation
    Right
    Left
    iii. Pelvic palpation
    Grip I
    Grip II
    c. Auscultation

     FHR
     Rate
    d. Findings

     Lie  Position
     Attitude  Engagement
     Presentation  FHR

    IV INVESTIGATIONS

    Date Specimen Examination Result Normal value Interpretation

     Radiographic (date)

    V MEDICATIONS

    Drugs/ Route/ Dose Action Side effects Nurse’s responsibility


    Pharmacological Name
    VI DIET PLAN
     Recommended calories
     Plan a day menu

    VII DISEASE ASPECT ( book picture should be compared with patient picture in detail)

    a.Definition
    b.Etiology and predisposing factors
    c.Pathophysiology
    d.Clinical manifestations
    e.Diagnostic measures
    f.Medical management
    - Definitive
    - Supportive
    g. Complications
    h. Prevention
    VIII NURSING MANAGEMENT
     List of nursing problems according to priority
     Nursing process
    IX DAILY NURSE’S PROGREESS NOTE

    X DISCHARGE PLAN AND HEALTH EDUCATION

    XI CONCLUSION

    XII BIBLIOGRAPHY

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