VENKETESHWAR COLLEGE OF NURSING

UDAIPUR

HIGH RISK ANTENATAL ASSESSMENT

SUBMITTED TO SUBMITTED BY

Mrs. Geetanjali Sharma Miss. Nanee Dhakar

HOD , Obstetrics and Gynaecology M.Sc Nursing Final Year

Submitted On :
Name : Mrs. Vishasini

Age : 22 yrs

Gravida :G1P1L1A0

Para: P1

Hospital number : 689407

Date of admission :24/4/2019

Weeks Of Gestation :37 weeks

Date Of Discharge :30/4/2019

Prenatal Record:

LMP: 12/07/2018

EDD:19/4/2019

Disease:

Hypertension : Nil

Genetic Disorder: Nil

Psychiatric Disorder

Menstural History

Menarchy: 14 yrs

Interval : 28-30 days

Duration : 4-5 days

Flow: Regular

Marital History :

Age of Marriage: 20 yrs

Consanguineous : No

Years Of Marriage : 2 years

Dietary Pattern

Vegetarian :Yes

Non Vegetarian : No

Likes : Homely Food

PAST OBSTETRICAL HISTORY :

SL Yea Full Preter Abortion Type Of Baby Remarks

No r Term m Deliver
y
Sex Alive Stillborn Weight

PRIMIGRAVIDA

Admission Notes :

Diagnosis :Rheumatic Heart Disease

General Condition: Poor

Heart : Tachycardia

Abdomen : Normal

Edema : Abdomen : Normal in palpation

Ankles: Present Digestion : Normal

Abdomen :Normal Pain: No

Blood Pressure :135/90 mm Hg

Lungs : Clear Mouth : No foul smell

Breast :Normal Nipple : Normal

Vulva : Normal Face : Pale

TPR: Good All over Body : Normal

Micturition : Burning Sensation Bowel : Normal

Vaginal Discharge : Present

Obstetrical History :

Preiod Of Gestation:37 weeks Presentation :Ce[halic

Height Of Fundus : 42 cm Enagaged /Not enagaged /Floating :Not engaged

Fetal Heart Rate :148/per minute Abdominal Girth : 62 cm

Investigation:

Blood Group : A RH :positive Hb :11 gm%

VDRL : -ve

HIV : Negative Ultra Sound : Normal

High Risk Factor : Rheumatic Heart Disease

Diet Ordered: Full diet

Treatment : Tab . Vavaron 2.25 gm , Cap. Eldervit (OD)

Remarks:

List Of Nursing diagnosis :

Nausea and Vomiting related to physiological changes in pregnancy

Anxiety and fear related to child birth process

Health Education :

 Advice patient for regular diet .

 Advice for maintenanace of hygiene .
 Take adequate diet and fluid
 Take medication at right time .
 Advice for follow up .