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MATERNAL ASSESSMENT

MATERNAL ASSESSMENT. Developed by D . Ann Currie,R.N . ,M.S.N. ANTEPARTAL NURSING ASSESSMENT. INITIAL CLIENT HISTORY INITIAL PRENATAL ASSESSMENT SUBSEQUENT PRENATAL VISIT ASSESSMENT. INITIAL CLIENT HISTORY. PERSONAL INFORMATION OBSTETRIC HISTORY GYNECOLOGIC HISTORY

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MATERNAL ASSESSMENT

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

  2. ANTEPARTAL NURSING ASSESSMENT • INITIAL CLIENT HISTORY • INITIAL PRENATAL ASSESSMENT • SUBSEQUENT PRENATAL VISIT ASSESSMENT

  3. INITIAL CLIENT HISTORY • PERSONAL INFORMATION • OBSTETRIC HISTORY • GYNECOLOGIC HISTORY • CURRENT MEDICAL HISTORY • PAST MEDICAL HISTORY • FAMILY MEDICAL HISTORY • SOCIOCULTURAL HISTORY

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

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

  6. PERSONAL INFORMATION • SUPPORT SYSTEM • CHILBIRTH PLANS • NEONATE PLANS

  7. OBSTETRIC HISTORY • TERMS • GRAVIDA-G • PARA-P • TPAL • GPTPAL • GTPAL

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

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

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

  11. GYNECOLOGIC HISTORY • PAP SMEAR • INFECTIONS • SURGERIES • MENARCHE • MENSTRUAL HISTORY • SEXUAL HISTORY • CONTRACEPTIVE USE

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

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

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

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

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

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

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

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

  20. PARTNER’S HISTORY • FAMILY MEDICAL HX • CONGENITAL PROBLEMS • ENVIRONMENTAL FACTORS • ATTITUDE TOWARDS PREGNANCY

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

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

  23. INITIAL PRENATAL ASSESSMENT • PSYCHOSOCIAL-CULTURAL ASSESSMENT • PHYSICAL ASSESSMENT • NUTRITIONAL ASSESSMENT • LEARNING NEEDS ASSESSMENT

  24. PSYCHOSOCIAL-CULTURAL ASSESSMENT • PSYCHOLOGICAL ASSESSMENT • SOCIOLOGICAL ASSESSMENT • CULTURAL ASSESSMENT

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

  26. PSYCHOLOGICAL ASSESSMENT • CONCERNS • FEARS

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

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

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

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

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

  32. HEAD TO TOE EXAMINATION • THIS MEANS EVERY SYSTEM. • COMPLETE EXAMINATION

  33. GYNECOLOGICAL EXAMINATION • VAGINAL EXAMINATION • PELVIC MEASUREMENTS • FUNDAL HEIGHT • EXTERNAL GENITALS • PAP SMEAR • ULTRASOUND • UTERUS • BREASTS

  34. CLINICAL MANIFESTATIONS OF PREGNANCY • SUBJECTIVE (PRESUMPTIVE) • OBJECTIVE (PROBABLE) • DIAGNOSTIC(POSITIVE) • NORMAL VS ABNORMAL

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

  36. Easy Way to Determine Due Date and Weeks Gestations

  37. FUNDAL MEASUREMENT

  38. FUNDAL HEIGHT AND WEEKS GESTATION

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

  40. LAB& DX TESTS • RUBELLA TITER • PAP SMEAR • OTHER AS INDICATED

  41. SUBSEQUENT PRENATAL VISITS ASSESMENT • FREQUENCY OF VISITS • PSYCHOSOCIAL ASSESSMENT • PHYSICAL ASSESSMENT • NUTRITIONAL ASSESSMENT • LEARNING NEEDS ASSESSMENT

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

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

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

  45. PSYCHOLOGICAL ASSESSMENT • PSYCHOLOGIC STATUS • DEVELOPMENTAL STAGE OF PREGNANCY • SEXUALITY DURING PREGNANCY • COPING • ATTITUDE • SUPPORT

  46. PHYSICAL ASSESSMENT • PHYSICAL EXAMINATION • DISCOMFORTS OF PREGNANCY • DANGER SIGNS

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

  48. NUTRITIONAL ASSESSMENT • LIKES/DISLIKES • ALLERGIES-FOOD • LEARNING NEEDS

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

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