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Antepartal nursing assessment

client profile assessment of mother during pregnancy and head to foot assessment assessment of fetal weight fundal height Edd , and fetal length etc

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Antepartal nursing assessment

  1. 1. ANTEPARTAL NURSING ASSESSMENT ANTEPARTAL NURSING ASSESSMENT Antepartum – refers to the medical & nursing care given to the woman between conception & onset of labor PURPOSE OF PRENATAL CARE: 1. establish a baseline of present health 2. determine fetal AOG (age of gestation) 3. monitor fetal development 4. identify the woman at risk of complications 5. minimize the risk of positive complications 6. provide time for education about pregnancy & possible dangers MAJOR CAUSES OF DEATH DURING PREGNANCY 1. intrapartum cardiac arrest 2. ectopic pregnancy 3. hypertension (can lead to ecclampsia) 4. embolism FOCUS OF PRENATAL CARE - to screen possible complications & danger such as: o hypertension o infection o bleeding or circulatory impairment DANGER SIGNS 1. Dysuria 2. Decrease fetal movement 3. Temp. > 101 F 4. Persistent vomiting 5. Severe abdominal pain 6. Gush of fluid from vagina 7. Vaginal bleeding DIAGNOSIS 1. sample: urine, serum 2. HCG: human chorionic Gonadotropin 3. 40-100th day; peak of 60 days PREGNANCY RISK FACTORS 1. age <18>35 2. decrease socioeconomic status 3. increase/ decrease weight 4. substance use/ abuse
  2. 2. 5. pre existing condition 6. –Rh factor 7. previous OB problem …possible cause 1. rupture or membrane 2. infection 3. hyperemesis gravidarum 4. HPN, preecclampsia 5. UTI 6. compromised fetal well-being A. Client history & initial interview 1. Establish rapport (harmonious relationship) 2. Gain information about the woman’s physical & psychological health 3. Obtain a basis for anticipatory guidance COMPONENT OF HEALTH HISTORY: 1. Demographic data Includes: - Name: - age: <18>35 (high risk) - address: - tel #: - religion: - health insurance information: 2. Chief concern (cc) Includes: - reason why the woman has come to the HC setting - inquire LMP (last menstrual period) - elicit information about: o signs of early pregnancy o discomforts of pregnancy o exposure to any contagious diseases o danger signs & pregnancy o medicine taken o planned or not 3. Family profile Inquire about: 1. marital status 2. couples’s age
  3. 3. 3. house structure 4. educational level 5. occupation 6. psychological assessment a. emotions b. support system c. stability & functional level of immediate & extended family d. economic support (housing, daily needs, medical expenses) e. family integrity promotion - involve family member in patient teaching sessions - teach family about impact of pregnancy & birth - encourage verbalization of feelings 4. Past medical History Inquire about: - pat medical disease - childhood disease - allergies/ drug – sensitivities - past surgical procedure o Medical/ Surgical History - PMH - allergies - PSH - nutritional history - Medicines - Substance use/ abuse 5. Family History ASK: - cardiovascular diseases - renal diseases - cognitive impairment - blood disorder - known inherited diseases - congenital anomalies - health status of parents/ siblings - Partner’s Health history o Genetic disorders o Chronic disease/ infection o Substance use/abuse o Blood type & Rh 6. Social Profile ASK: - type, amount, frequency - smoking/ dringking habits - spouse abuse
  4. 4. - medication history - prenatal health education o substance use/abuse o smoking (risk for: prematurity, cognitive problem) o illegal drug use (risk for: abruption, preterm labor, CNS dysfunction) 7. Gynecologic History ASK: - information about menarche - past surgery on the reproductive tract - reproductive planning method - sexual history - stress incontinence - menstrual history o onset of menses o regularity o LMP o Length of cycle - contraceptives o types/used o Oral contraceptive is contraindicated 3 months prior to pregnancy o IUD (risk: increase spon. Abortion) 8. Obstetric History ASK: - history of previous pregnancy - history of present pregnancy - (GTPALM) gravida, term, para, abortion, living children, multiple pregnancy - Types of preganancy/ delivery - Methods of feeding - Maternal/ infant complications - Maternal Psychological adaptations to pregnancy o 1st trimester (focus on self) “I am pregnant” o 2nd trimester (focus on baby) “I am going to have baby” o 3rd trimester “I am going to be a mom” G - # or pregnancy regardless of the result T - # of full term infant (born 37 wks or after) P - # of preterm (born b/w 20-37 wks) A - # of spontaneous abortion (before 20 wks) L - # of living children currently alive M – Multiple pregnancies
  5. 5. GP – describe woman’s childbearing history GRAVIDA – total # of pregnancy PARA - # of birth after 20 wks of gestation/ 24-28 wks > born dead or alive > Multiple births (regardless of # of infant count as delivery) (See example) 9. Typical day history B. Definition of terms (Terms associated with pregnancy) Gestational menstrual age (GMA) -measured from the 1st day of the last normal menstruation period, in completed days Ovulation (post- conception) age -2 weeks gestational age Age of Viability -in Philippines: 24-26 wks -US: 20-24 wks -beyond 24th week of pregnancy is the stage of abortion Obstetrical score (GTPALM) – full term – premature – abortions – live children – multiple births Parturition -process of labor Parturient -woman in labor Puerperium -6-8 wks period Abortion -medical term for any pregnancy terminated before age of viability Preterm -a pregnancy that ends after 20 wks & before 37 wks of gestation Post term -pregnancy that goes beyond 40 wks of gestation Still birth -fetus born dead after 20 wks gestation 1. PARITY -number of pregnancies reaching viability. Same whether a single or multiple fetuses were born alive/ stillborn -born past the age of viability primipara -delivered only 1 fetus w/c reached viability Multipara -delivered 2 or more fetus w/c reached the viability Nullipara -never completed pregnancy or the age of viability 2. GRAVIDA -woman who is/ who has been pregnant irrespective of pregnancy outcome Primigravida -1st pregnancy Multigravida -successive pregnancy -has been pregnant previously Nulligravida -who has never been pregnant C. Initial Physical Assessment with each Prenatal Visit should include
  6. 6. a.) Vital Sign (BP, PR, RR, weight) Review of system: Head o (injury, seizures, dizziness) Eyes o (vision, glasses, infection, diplopia-double vision) Ears o (infection, discharge, tinnitus, vertigo, hearing loss-due to increase in estrogen there is also an increase in production of mucous) Nose o (epistaxis, discharge, colds, allergy, sinus pain) Mouth o (pharynx dentures, teeth, gums, tonsillectomy) Neck o (stiffness, masses) Breast o (lumps, secretion, pain, tenderness, breast self exam) Respiratory o (cough, wheezing, asthma, pain, shortness of breaths, PTB) Cardiovascular o (heart disease, murmur, palpitation, hypertension) GIT o (vomiting, diarrhea, constipation) Genitourinary system o (urinary frequency) Extremities o (edema) Skin o (rashes, acne, psoriasis) * Assessment from head to toe of major body system * watch for an elevations of BP Increase 30: systolic Decrease 15: diastolic b.) Weight Average weight gain: 24-30 lbs a. fetus = 7.5 lbs b. placenta & membrane = 1.5 lb c. amniotic fluid = 2 lb d. uterus = 2.5 lb
  7. 7. c.) Physical Examination Check for: - General appearance & mental status - Head & scalp (contour, symmetry, tenderness, dry) - Eyes (edema, spots, diplopia) - Nose (nasal congestion) - Ears (nasal stiffness) - Sinuses (should feel tender) - Mouth, teeth & throat - Neck (slight thyroid hypertrophy) - Lymph (no palpable lymph nodes) - Breast (areola darkens, size increase) - Heart (70-80 beats) - Back (scoliosis) - Extremities & skin (hemorrhoids, palmar erythema, varicosities) d.) DURATION OF PREGNANCY - 266-280 days - (38-42 weeks; average 40) - 9 calendar month - 10 lunar month/ 1 lunar month=28 days • Perinatal period – start at 22 completed weeks of gestation & ends 7 completed days after birth • Neonatal Period – from birth to 28 days of birth DETERMINATION OF DELIVERY DATE We can use: 1. Naegele’s rule 2. McDonald’s rule 3. Bartholomew’s rule 4. Haase’s rule 5. Johnson’s rule ooOoo 1. Naegele’s rule (Expected date of confinement) Formula: (1st day of LMP) + 7 days – 3 months + 1 year
  8. 8. Example 1: LMP: 10 July, 2006 10 7 06 + 7 - 3 + 1 17 4 07 Thus, EDC: 17 April, 2007 Example 2: LMP: 31 January, 2008 31 01 08 + 7 - 3 38 - 31 + 1 7 - 1 +12 7 11 08 Note: - not applicable for January to March 24 (Add 12 to months) - March 25 – December (add 1 to the year) 2. McDonald’s rule (Estimation of the duration of the pregnancy) - estimation using the fundic height o fundal height (measured from symphisis pubis to top of uterus) o used to app. Fetal age (in weeks) - application from 22-34 weeks age of gestation - FORMULA: Distance in cm * 8 = total gestational 7 age Note: inaccurate in 3rd trimester 3. Batholomew’s rule - a tape measure is unavailable, these rough guidelines can be used: 3rd mo. – slightly above 5th mo. – symphisis pubis, umbilicus 9th mo. – below xiphoids Fundic Height (in cm) = week AOG e.g. If fundus is 24 cm = fetus is 24 week AOG Alternative method: Use fundus as a landmark AOG
  9. 9. - Above symphysis pubis 12 - Halfway b/w symphisis pubis & umbilicus 16 - Level of Umbilicus 20 - 6 cm above SP 28 weeks - 2 cm above SP 36 weeks - 4 cm above SP 40 weeks 4. Haase’s rule - determine length of fetus in cm - 1st half of pregnancy (20 weeks) – square the number of the month (4 ½ mon.) - 2nd half of pregnancy – multiply the no. by 5 Example: (1st half) 3 mon. * 3 old = 9 cm long (2nd half) 6 mon. * 5 old = 30 cm long 5. Johnson’s rule - estimates the weight of the fetus in grams - FORMULA: o [ (funic height in cm) – h ] * K K is constant = 155 N is = 12, if the fetus is engaged 11, if unengaged e.) UTERINE ASSESSMENT 1. Fundal height 2. Fetal heart sounds - 120-160 bpm - 10-12 wks heard by “Doppler technique” - 18-20 wks heard by a regular stethoscope - After 28th weeks = fetal outline & position can be palpated 3. Fetal growth & development 4. Pelvic adequacy/ examination Equipments: - Speculum - culture tube - Spatula - Gloves - Glass slide -Sterile cotton; tipped applicator (2-3)
  10. 10. Specimen taken 1. edocervix 2. cervical OS 3. vaginal pool Cardinal rule: Empty bladder first Position: Dorsal Lithotomy f.) LABORTAORY ASSESSMENTS a. Blood studies 1. CBC – HCT, HgB, RBC, WBC 2. VDRL – Papanicolaou Smear What is a Pap smear? - test to check the health of your cervix (opening of uterus/ womb) - sometimes change occurs in the cell of the cervix & abnormal cell develop - treatment of these changes can prevent cervix cancer Papanicolaou Screen & Cytologic study - screen for cervical dysplasia & assess hormone cytology & inflammatory disease of genital tract 3. Blood typing 4. Indirect Coomb’s Test 5. Rubella Titer 6. Hepa B & HIV screening 7. Rh b. Urinalysis (clean catch urine) - performed to assay for albumin, glycosuria (diabetes), ketones (breakdown of protein), leukocytes (WBC), pyuria (presence of pus) c. TB screening - Chest X-ray - Tuberculin skin test D. Return Visits Schedule: • Every 4 weeks - 1st 28th week/ 7 months • Every 2 weeks – until the 36th week • Every week – until delivery *More frequent visit: as the need arises
  11. 11. Subsequent Visits 1. Assessment a. Maternal & fetal Evaluation - BP, PR, RR, T - Weight - FHR: 120-160 - Fundus height o 30 cm estimate: 6 – 6 ½ lbs o 31 cm: 6 ½ - 7 lbs o 32 cm: 7 – 7 ½ lbs b. Lab test c. Symptoms felt d. Vaginal/ internal examination 2nd Trimester - Period of rapid growth - Monthly visits - General, emotional, physical well being - Questions - Success failure of self care Interview Must be: 1. Careful 2. Precise 3. Concise 4. Checklist of care – used as communication tool

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