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Introduction SJUznSXNU&feature=fvwrel SJUznSXNU&feature=fvwrel

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Presentation on theme: "Introduction SJUznSXNU&feature=fvwrel SJUznSXNU&feature=fvwrel"— Presentation transcript:

1 Introduction http://www.youtube.com/watch?v=9k SJUznSXNU&feature=fvwrel http://www.youtube.com/watch?v=9k SJUznSXNU&feature=fvwrel http://www.youtube.com/watch?v=9k SJUznSXNU&feature=fvwrel http://www.youtube.com/watch?v=9k SJUznSXNU&feature=fvwrel

2 MATERNAL ASSESSMENT Developed by D. Ann Currie R.N.,M.S.N. 2012

3

4 ANTEPARTAL NURSING ASSESSMENT INITIAL CLIENT HISTORY INITIAL CLIENT HISTORY INITIAL PRENATAL ASSESSMENT INITIAL PRENATAL ASSESSMENT SUBSEQUENT PRENATAL VISIT ASSESSMENT SUBSEQUENT PRENATAL VISIT ASSESSMENT

5 INITIAL CLIENT HISTORY PERSONAL INFORMATION PERSONAL INFORMATION OBSTETRIC HISTORY OBSTETRIC HISTORY GYNECOLOGIC HISTORY GYNECOLOGIC HISTORY CURRENT MEDICAL HISTORY CURRENT MEDICAL HISTORY PAST MEDICAL HISTORY PAST MEDICAL HISTORY FAMILY MEDICAL HISTORY FAMILY MEDICAL HISTORY SOCIOCULTURAL HISTORY SOCIOCULTURAL HISTORY

6 INITIAL CLIENT HISTORY CONT. CONT. OCCUPATIONAL HISTORY OCCUPATIONAL HISTORY PARTNER’S HISTORY PARTNER’S HISTORY STRATEGIES FOR OBTAINING DATA STRATEGIES FOR OBTAINING DATA PRENATAL HIGH-RISK SCREENING PRENATAL HIGH-RISK SCREENING

7 PERSONAL INFORMATION NAME NAME AGE AGE OCCUPATION OCCUPATION MARITAL STATUS MARITAL STATUS EDUCATION LEVEL EDUCATION LEVEL RACE,ETHNIC GROUP RACE,ETHNIC GROUP ADDRESS,PHONE NUMBER ADDRESS,PHONE NUMBER

8 PERSONAL INFORMATION SUPPORT SYSTEM SUPPORT SYSTEM CHILBIRTH PLANS CHILBIRTH PLANS NEONATE PLANS NEONATE PLANS

9 OBSTETRIC HISTORY TERMS TERMS GRAVIDA-G GRAVIDA-G PARA-P PARA-P TPAL TPAL GPTPAL GPTPAL GTPAL GTPAL

10 OBSTETRICAL HISTORY GPTPAL GPTPAL ABORTIONS-WHEN IN GESTATION.TYPE,COMPLICATIONS. ABORTIONS-WHEN IN GESTATION.TYPE,COMPLICATIONS. HX OF PREVIOUS PREGNANCIES- GESTATION LENGTH,COMPLICATIONS,OUTCOME HX OF PREVIOUS PREGNANCIES- GESTATION LENGTH,COMPLICATIONS,OUTCOME LABOR- LENGTH,COMPLICATIONS,OUTCOME LABOR- LENGTH,COMPLICATIONS,OUTCOME

11 OBSTETRICAL HISTORY TYPE OF DELIVERY- COMPLICATIONS.OUTCOME TYPE OF DELIVERY- COMPLICATIONS.OUTCOME TYPE OF ANESTHESIA- COMPLICATIONS TYPE OF ANESTHESIA- COMPLICATIONS POSTPARTAL EVENTS POSTPARTAL EVENTS NEONATAL STATUS-WEIGHTS,APGAR SCORES, COMPLICATIONS NEONATAL STATUS-WEIGHTS,APGAR SCORES, COMPLICATIONS

12 CONT. OB HX BLOOD TYPE&RH (Was Rhogam given if client is RH-negitive?) BLOOD TYPE&RH (Was Rhogam given if client is RH-negitive?) CHILDBIRTH EDUCATION-type and when CHILDBIRTH EDUCATION-type and when

13 GYNECOLOGIC HISTORY PAP SMEAR PAP SMEAR INFECTIONS INFECTIONS SURGERIES SURGERIES MENARCHE MENARCHE MENSTRUAL HISTORY MENSTRUAL HISTORY SEXUAL HISTORY SEXUAL HISTORY CONTRACEPTIVE USE CONTRACEPTIVE USE

14 CURRENT MEDICAL HISTORY WEIGHT-CURRENT & PREPREGNANT WEIGHT-CURRENT & PREPREGNANT HEIGHT HEIGHT BMI BMI BLOOD-TYPE&RH BLOOD-TYPE&RH GENERAL HEALTH GENERAL HEALTH NUTRITION NUTRITION EXERCISE EXERCISE

15 CURRENT MEDICAL HISTORY SUBSTANCE ABUSE/USE SUBSTANCE ABUSE/USE MEDICATIONS- OTC,HERBS,PRESCRIPTIONS MEDICATIONS- OTC,HERBS,PRESCRIPTIONS ALLERGIES ALLERGIES ENVIRONMENTAL FACTORS ENVIRONMENTAL FACTORS CURRENT DISEASES OR CONDITIONS CURRENT DISEASES OR CONDITIONS IMMUNIZATIONS IMMUNIZATIONS

16 CONT.CURRENT MED,HX. CLINCAL MANIFESTATIONS OF PREGNANCY CLINCAL MANIFESTATIONS OF PREGNANCY ABNORMAL S/S ABNORMAL S/S

17 PAST MEDICAL HISTORY CHILDHOOD DISEASES CHILDHOOD DISEASES PAST DISEASES OR CONDITIONS- IE STI’S,UTI’S,RHEUMATIC FEVER. PAST DISEASES OR CONDITIONS- IE STI’S,UTI’S,RHEUMATIC FEVER. SURGERIES SURGERIES BLEEDING PROBLEMS BLEEDING PROBLEMS TRANSFUSIONS TRANSFUSIONS

18 FAMILY MEDICAL HISTORY HEALTH STATUS OF FAMILY HEALTH STATUS OF FAMILY DISEASES &/OR CONDITIONS DISEASES &/OR CONDITIONS MULTIPLE BIRTHS MULTIPLE BIRTHS CONGENITAL CONDITIONS CONGENITAL CONDITIONS MENTAL ILLNESS MENTAL ILLNESS C/S C/S CAUSE OF DEATH OF FAMILY CAUSE OF DEATH OF FAMILY

19 SOCIOCULTURAL HISTORY OCCUPATION OCCUPATION ED LEVEL ED LEVEL RELIGION RELIGION RACE,ETHNIC GROUP RACE,ETHNIC GROUP AGE AGE BELIEFS & PRACTICES- HEALTH,CHILDBIRTH, CHILDREARING BELIEFS & PRACTICES- HEALTH,CHILDBIRTH, CHILDREARING

20 OCCUPATIONAL HISTORY OCCUPATION OCCUPATION WHAT IS DONE IN OCCUPATION? WHAT IS DONE IN OCCUPATION? ACTIVITIES ACTIVITIES PHYSICAL DEMANDS PHYSICAL DEMANDS EXPOSURE TO ENVIRONMENTAL FACTORS EXPOSURE TO ENVIRONMENTAL FACTORS BREAKS BREAKS

21 PARTNER’S HISTORY NAME NAME AGE AGE HEALTH STATUS HEALTH STATUS SUBSTANCES USE SUBSTANCES USE BLOOD TYPE & RH BLOOD TYPE & RH OCCUPATION OCCUPATION ED LEVEL ED LEVEL

22 PARTNER’S HISTORY FAMILY MEDICAL HX FAMILY MEDICAL HX CONGENITAL PROBLEMS CONGENITAL PROBLEMS ENVIRONMENTAL FACTORS ENVIRONMENTAL FACTORS ATTITUDE TOWARDS PREGNANCY ATTITUDE TOWARDS PREGNANCY

23 STRATEGIES FOR OBTAINING DATA QUESTIONNAIRE QUESTIONNAIRE DIRECT INTERVIEW WITH CLIENT DIRECT INTERVIEW WITH CLIENT EXPECTANT FATHER EXPECTANT FATHER PHYSICAL EXAMINATION PHYSICAL EXAMINATION LABORATORY & DX TESTS LABORATORY & DX TESTS CLARIFY INFORMATION CLARIFY INFORMATION ANSWER QUESTIONS ANSWER QUESTIONS

24 PRENATAL HIGH-RISK SCREENING SOCIOECONOMIC FACTORS SOCIOECONOMIC FACTORS ENVIRONMENTAL FACTORS ENVIRONMENTAL FACTORS MEDICAL HISTORY MEDICAL HISTORY DAILY HABITS DAILY HABITS SUBSTANCE USE SUBSTANCE USE CLINICAL MANIFESTATIONS- ABNORMAL FOR GESTATION CLINICAL MANIFESTATIONS- ABNORMAL FOR GESTATION

25 HIGH RISK SCREENING ABUSE SCREENING ABUSE SCREENING SCREEN FOR RISK FOR DVTs SCREEN FOR RISK FOR DVTs

26 INITIAL PRENATAL ASSESSMENT PSYCHOSOCIAL-CULTURAL ASSESSMENT PSYCHOSOCIAL-CULTURAL ASSESSMENT PHYSICAL ASSESSMENT PHYSICAL ASSESSMENT NUTRITIONAL ASSESSMENT NUTRITIONAL ASSESSMENT LEARNING NEEDS ASSESSMENT LEARNING NEEDS ASSESSMENT

27 PSYCHOSOCIAL- CULTURAL ASSESSMENT PSYCHOLOGICAL ASSESSMENT PSYCHOLOGICAL ASSESSMENT SOCIOLOGICAL ASSESSMENT SOCIOLOGICAL ASSESSMENT CULTURAL ASSESSMENT CULTURAL ASSESSMENT

28 PSYCHOLOGICAL ASSESSMENT HX OF MENTAL CONDITIONS HX OF MENTAL CONDITIONS CURRENT MENTAL CONDITIONS CURRENT MENTAL CONDITIONS ABUSE SCREENING ABUSE SCREENING DEPRESSION SCREENING DEPRESSION SCREENING ANXIETY SCREENING ANXIETY SCREENING EMOTIONAL SUPPORT EMOTIONAL SUPPORT ATTITUDE TOWARDS PREGNANCY ATTITUDE TOWARDS PREGNANCY

29 PSYCHOLOGICAL ASSESSMENT CONCERNS CONCERNS FEARS FEARS

30 SOCIOLOGIAL ASSESSMENT INCOME LEVEL INCOME LEVEL LIVING CONDITIONS LIVING CONDITIONS FINICIAL SUPPORT FINICIAL SUPPORT INSURNCE INSURNCE MARITAL STATUS MARITAL STATUS ED LEVEL ED LEVEL FAMILY SIZE &LOCATION FAMILY SIZE &LOCATION

31 CULTURAL ASSESSMENT RELIGION RELIGION BELIEFS AND PRACTICES-HEALTH- ILLNESS,CHILBIRTH,CHILDREARING, ROLES,DIETARY,BLOOD PRODUCTS. BELIEFS AND PRACTICES-HEALTH- ILLNESS,CHILBIRTH,CHILDREARING, ROLES,DIETARY,BLOOD PRODUCTS. SPIRITUAL WELL-BEING SPIRITUAL WELL-BEING PARTNER’S BELIEF AND PRACTICES WITH ABOVE TOPICS. PARTNER’S BELIEF AND PRACTICES WITH ABOVE TOPICS. ETHNIC GROUP ETHNIC GROUP

32 PHYSICAL ASSESSMENT PREPARATION FOR THE EXAMINATION PREPARATION FOR THE EXAMINATION HEAD TO TOE EXAMINATION HEAD TO TOE EXAMINATION GYNECLOGIC EXAMINATION GYNECLOGIC EXAMINATION CLINICAL MANIFESTATIONS OF PREGNANCY CLINICAL MANIFESTATIONS OF PREGNANCY DETERMINE OF DUE DATE DETERMINE OF DUE DATE LABORATORY AND DX TESTS LABORATORY AND DX TESTS

33 PREPARATION FOR THE EXAMINATION KNOW THE PROCEDURE-WHAT IS GOING TO BE DONE,EQUIPMENT IS READY. KNOW THE PROCEDURE-WHAT IS GOING TO BE DONE,EQUIPMENT IS READY. ASSESS CLIENTS KNOWLEDGE OF PROCEDURE ASSESS CLIENTS KNOWLEDGE OF PROCEDURE CONSENT IS GIVE CONSENT IS GIVE ASK QUESTIONS ASK QUESTIONS ANSWER QUESTIONS ANSWER QUESTIONS

34 PREPARATION FOR EXAMINATION ADDRESS CONCERNS AND FEARS. ADDRESS CONCERNS AND FEARS. EXPLAIN PROCEDURE. EXPLAIN PROCEDURE. SUPPORT PERSON SUPPORT PERSON RELAXATION TECHNIQUES RELAXATION TECHNIQUES CULTURAL ISSUES CULTURAL ISSUES BLADDER BLADDER ENVIRONMENT ENVIRONMENT

35 HEAD TO TOE EXAMINATION THIS MEANS EVERY SYSTEM. THIS MEANS EVERY SYSTEM. COMPLETE EXAMINATION COMPLETE EXAMINATION

36 GYNECOLOGICAL EXAMINATION VAGINAL EXAMINATION VAGINAL EXAMINATION PELVIC MEASUREMENTS PELVIC MEASUREMENTS FUNDAL HEIGHT FUNDAL HEIGHT EXTERNAL GENITALS EXTERNAL GENITALS PAP SMEAR PAP SMEAR ULTRASOUND ULTRASOUND UTERUS UTERUS BREASTS BREASTS

37 CLINICAL MANIFESTATIONS OF PREGNANCY SUBJECTIVE (PRESUMPTIVE) SUBJECTIVE (PRESUMPTIVE) OBJECTIVE (PROBABLE) OBJECTIVE (PROBABLE) DIAGNOSTIC(POSITIVE) DIAGNOSTIC(POSITIVE) NORMAL VS ABNORMAL NORMAL VS ABNORMAL

38 DETERMINATION OF DUE DATE LMP LMP NAGEL’S RULE NAGEL’S RULE FUNDAL HEIGHT FUNDAL HEIGHT QUICKENING QUICKENING FETAL HEARTBEAT FETAL HEARTBEAT DX TESTS-SONOGRAM DX TESTS-SONOGRAM

39 Easy Way to Determine Due Date and Weeks Gestations

40 FUNDAL MEASUREMENT

41 FUNDAL HEIGHT AND WEEKS GESTATION

42 LABORATORY AND DX TESTS CBC CBC UA UA PREGNANCY TESTS PREGNANCY TESTS STI’S-RPR-VDRL-FTA- ABS,GONORRHEA,HIV,HEPB,GBS, CHLAMYDIA,HERPES. STI’S-RPR-VDRL-FTA- ABS,GONORRHEA,HIV,HEPB,GBS, CHLAMYDIA,HERPES. BLOOD- BLOOD- TYPE&RH,ANTIBODIES(Indirect COOMBS) TYPE&RH,ANTIBODIES(Indirect COOMBS)

43 LAB& DX TESTS RUBELLA TITER RUBELLA TITER PAP SMEAR PAP SMEAR OTHER AS INDICATED OTHER AS INDICATED

44 SUBSEQUENT PRENATAL VISITS ASSESMENT FREQUENCY OF VISITS FREQUENCY OF VISITS PSYCHOSOCIAL ASSESSMENT PSYCHOSOCIAL ASSESSMENT PHYSICAL ASSESSMENT PHYSICAL ASSESSMENT NUTRITIONAL ASSESSMENT NUTRITIONAL ASSESSMENT LEARNING NEEDS ASSESSMENT LEARNING NEEDS ASSESSMENT

45 FREQUENCY OF VISITS AS INDICATED BY CLIENT’S CONDITION AND HISTORY AS INDICATED BY CLIENT’S CONDITION AND HISTORY ROUTINE-INITIAL,ONCE A MONTH,THEN TWICE A MONTH,THEN EVERY WEEK. ROUTINE-INITIAL,ONCE A MONTH,THEN TWICE A MONTH,THEN EVERY WEEK.

46 SUBSEQUENT VISITS VS VS WEIGHT WEIGHT EDEMA EDEMA UTERINE SIZE UTERINE SIZE FHR FHR LAB-UA FOR PROTIEN,GLUCOSE,OTHER LAB-UA FOR PROTIEN,GLUCOSE,OTHER

47 CONT. CLINICAL MANIFESTATIONS OF PREGNANCY-NORMAL CLINICAL MANIFESTATIONS OF PREGNANCY-NORMAL WARNING SIGNS WARNING SIGNS CONCERNS CONCERNS QUESTIONS QUESTIONS LEARNING NEEDS LEARNING NEEDS

48 PSYCHOLOGICAL ASSESSMENT PSYCHOLOGIC STATUS PSYCHOLOGIC STATUS DEVELOPMENTAL STAGE OF PREGNANCY DEVELOPMENTAL STAGE OF PREGNANCY SEXUALITY DURING PREGNANCY SEXUALITY DURING PREGNANCY COPING COPING ATTITUDE ATTITUDE SUPPORT SUPPORT

49 PHYSICAL ASSESSMENT PHYSICAL EXAMINATION PHYSICAL EXAMINATION DISCOMFORTS OF PREGNANCY DISCOMFORTS OF PREGNANCY DANGER SIGNS DANGER SIGNS

50 NUTRITIONAL ASSESSMENT WEIGHT WEIGHT HEIGHT HEIGHT BMI BMI WEIGHT GAIN/LOSS WEIGHT GAIN/LOSS DIETARY HISTORY& INTAKE DIETARY HISTORY& INTAKE CULTURAL FACTORS CULTURAL FACTORS PHYSICAL EXAMINATION PHYSICAL EXAMINATION

51 NUTRITIONAL ASSESSMENT LIKES/DISLIKES LIKES/DISLIKES ALLERGIES-FOOD ALLERGIES-FOOD LEARNING NEEDS LEARNING NEEDS

52 LEARNING NEEDS ASSESSMENT HEALTH PROMOTION HEALTH PROMOTION PREGNANCY- PHYSICAL&PSYCHOLOGICAL ASPECTS,DISCOMFORTS.SELF-HELP MEASURES PREGNANCY- PHYSICAL&PSYCHOLOGICAL ASPECTS,DISCOMFORTS.SELF-HELP MEASURES DANGER SIGNS DANGER SIGNS CHILDBIRTH CHILDBIRTH CHILDCARE CHILDCARE

53 LEARNING NEEDS BIRTHPLAN BIRTHPLAN INCLUDE SUPPORT PERSON INCLUDE SUPPORT PERSON RESOURCES RESOURCES ***PRECONCEPTION**** ***PRECONCEPTION**** GENERAL PUBLIC GENERAL PUBLIC

54

55 QUESTIONS

56 THANK YOU http://www.youtube.com/watch?v=9C CnsQyWBEc&feature=related http://www.youtube.com/watch?v=9C CnsQyWBEc&feature=related http://www.youtube.com/watch?v=9C CnsQyWBEc&feature=related http://www.youtube.com/watch?v=9C CnsQyWBEc&feature=related


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