Presentation on theme: "Admission Assessment of the Pregnant Woman"— Presentation transcript:
1 Admission Assessment of the Pregnant Woman Evelyn M. Hickson, RN, MSN, CNS, WCC
2 ObjectivesIdentify potential complications of pregnancy based on prenatal history, physical assessment and lab values.Discuss the role of the perinatal nurse in screening, identifying, documenting and referring patients with history of domestic violence or substance use during pregnancy.Discuss maternal infections, modes of treatment, and potential impact on the infant.(HIV TB, STDs, Hepatitis, Herpes, GBS)
3 Review of Prenatal Records Review office reports, includingObstetrical historyPersonal medical historyFamily historySocial historyNote any areas of concern identified by the care providerFamily history concerns: cardiac disease, DM, bleeding disordersExamples of pregnancy-related concerns: previous postpartum hemorrhage, previous c-section, previous stillborn, previous preterm labor or birth, elevated blood pressures during pregnancy, gestational diabetes, etc.
4 Prenatal Labs Blood type and antibody screen Rubella immunity GBS cultureHSVHIVHepatitis BVDRL/RPRQuad screenGlucose tolerance testing
5 OB History: Current Pregnancy Maternal ageEDCDating criteriaHow early did she start prenatal care?GestationCurrent complicationsGTPALGravidityTerm birthsPreterm (<37 wk) birthsAbortions (elective, therapeutic or spontaneous)Living childrenEarly prenatal care allows for greater opportunity to identify potential medical or social risks for the patient and fetus and is associated with improved pregnancy outcomes. (Simpson and Creehan, 1996).How many prenatal visits? Every 4 weeks the first 28 weeks of pregnancy, every 2 weeks until 36 weeks, then weekly until delivery.Do they live with you? How old is your youngest child?Occasionally when reviewing these events with patients they will remember pregnancies that they did not report to their care provider. How fresh their memories are for childbirth could be influenced by how many years back was the last baby.
6 OB History: Multiparous Patients Length of previous labors, infant birth weight, gestational age at deliveryHistory of preterm labor or deliveryPrevious operative deliveryPrevious stillbirthHistory of postpartum hemorrhage or postpartum depression
7 Social History Marital status or available family support CPS or other alertsSocial/economic/educational concernsPhysical/mental challengesReferral to social servicesLanguage barriersReligious or cultural practices
8 Prioritizing the Patient Interview Sometimes the urgency of the situation dictates the order in which one proceeds with a patient interview, such as:Imminent deliveryUnstable maternal condition (Unconscious, bleeding, seizing, etc)Category 3 fetal tracingAppropriate to gather information from support people that may be present in either of these situations.
9 Patient Interview Note the date and time of patient arrival Is your baby moving?Are you contracting? If so, when did they start and how often are they occurring?Are you experiencing vaginal bleeding, discharge, or leaking of fluid?Are you in pain? Orient the patient to the pain scale and discuss her plans for pain management.Send them to bathroom for UA.What brings you here?Have you had intercourse in the past 12 to 24 hours?Consider posting crisis card line in bathroom, so that women experiencing domestic violence may discreetly get information.
10 Patient Interview (cont.) Current medicationsDose, route, last takenAllergies and reactionsWhen the patient last ate or drank (including what was eaten or drunk)Recent SVEComplications with current or previous pregnancy
11 Is the patient experiencing… Nausea or vomitingFrequency or burning with urinationEpigastric painHeadachesVisual disturbances
12 Physical Assessment Leopold’s Maneuvers EFM Orient patient to monitors and basic strip interpretationWhen you are doing a physical assessment, look for any unusual marks or bruises. Note patient’s demeanor and reactions to procedures. Make sure she understands what you are going to do and why before you proceed.Ask: what are some contraindications to an SVE?
13 Physical Assessment Vital signs (full set) Urine dip Physical exam including:EdemaDTRs and ClonusBreath sounds if patient presents with respiratory symptomsSVE – unless contraindicated
14 Labor Assessment Time contractions started Frequency, duration, and regularity of contractionsPalpation of maternal abdomen during and between contractionsFetal movementPain assessment, including location and type of pain
15 Herbs/Foods That Increase Uterine Activity Bitter MelonCastor bean or castor oilChamomile teaCinnamon (spice tea)GarlicGingerGoldensealPomegranateRed raspberry leaf tea
16 Suspected Rupture of Membranes Intercourse in last hoursTime possible SROM occurredColor, amount, and smell of fluidTesting of vaginal discharge for presence of amniotic fluidIf the patient is between 24 and 34 weeks gestation, sterile speculum exam for testing of ROM and collection of FFN may be indicated.
17 Substance Use and Abuse Warning signs of drug abuse:Noncompliance with prenatal care – late entry or no prenatal carePoor nutrition –due to adolescence, obesity, low socioeconomic statusCurrent or previous history of encounters with law enforcementMarital & family disputesIntrapartum signs of substance abuseUnexplained IUGR3rd trimester stillbirthUnexpected preterm birthPlacental abruption in a woman without hypertensive disorders.Informed consent for testingSocial service consult, CPS, drug treatmentQuestions need to be non-threatening and non-judgmental.Questions like when have you last used…. Are sometimes helpful.
18 Domestic ViolenceMajority of abused women continue to be victimized during pregnancy and may escalate. Most estimate rates between 4 –8%.Child abuse occurs in 33 – 77% of families with adult abuse.No single profile of an abused woman: all racial, economic, educational, religious, ethnic and social backgrounds.Where will you find evidence of abuse on the patient’s body?What kind of behavior do you assess in the abused patient and her abuser?
19 Pregnancy and Domestic Violence Signs of domestic violence in the pregnant patient include:unwanted pregnancylate entry into prenatal caremissed appointmentssubstance abuse or usepoor weight gain and nutritionmultiple, repeated somatic complaints.
20 Domestic Violence Screening Should be conducted in private, with only the patient present“Because violence against women is so common, I ask all of my patients do you have any reason to feel unsafe at home?”Document patient statements accurately and quote them directly
21 Promptly Notify Care Provider if: Vaginal bleedingAcute abdominal painTemperature of F or higherPreterm laborPreterm rupture of membranesHypertensionNon-reassuring fetal heart rate pattern
22 SBAR Communication Best method to speak to providers Gives you a standard list of things you need to be prepared to discuss with themBe concise and factualDo not use “touchy-feely” language
23 SBAR Communication Situation What is going on with the patient? BackgroundWhat is the clinical context?AssessmentWhat do I think the problem is?RecommendationWhat would I do to correct it?Remember that you may be speaking with a care provider that is not familiar with the patient.
24 SBAR Guideline Prior to calling the provider: Have I assessed the patient myself?Has the situation been discussed with a resource nurse or preceptor?Have the following available when speaking:Patient chartList of current medications, allergies, whether IV was placed and labs drawnMost recent vital signsReporting lab results: provide the date and time test was done and results of previous labs for comparison
25 SBAR: Situation What is the situation you are calling about? Identify self, unit, patient, room numberState who the patient’s doctor has been for the pregnancyBriefly state the problem, what is it, when it happened or started, and how severe.
26 SBAR: BackgroundPertinent background information related to the situation could include:Gestation, GTPAL, age, previously identified risk factorsList of current medications, allergies, labsMost recent vital signsClinical information
27 SBAR: Assessment and Recommendation What is your assessment of the situation?What is your recommendation or expectation?Admission for laborPatient needs to be seen nowPatient needs antibiotics for UTI, etc.Document the care provider notification, orders received, changes in patient condition, and plan.
28 Guidelines for Communication with Physicians Using SBAR Use the following according to provider preference.Direct pageCall serviceDuring weekdays, the office directlyOn weekends and after hours during the week, home phoneCell phone.Wait no longer than 5 minutes between attempts.For emergent situations, use the appropriate chain of command as needed to ensure safe patient care.
29 References Guidelines for Perinatal Care, (6th ed.)/AAP and ACOG, 2005 Lowdermilk, D. and Perry, S. (2007). Maternity and Women’s Health Care (9th ed.). St. Louis, MI: Mosby Elsevier.Mattson, S. and Smith, J. (2004). Core Curriculum for Maternal-Newborn Nursing (3rd ed.). St. Louis, MI: Mosby Elsevier.Simpson, K. and Creehan, P. (2010). Perinatal Nursing (3rd ed.). Philadelphia, PA: Lippincott.