Introduction
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http://www.youtube.com/watch?v=9k
SJUznSXNU&feature=fvwrel
MATERNAL
ASSESSMENT
Developed by
D. Ann Currie R.N. ,M.S.N.
2012
ANTEPARTAL NURSING
ASSESSMENT
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INITIAL CLIENT HISTORY
INITIAL PRENATAL ASSESSMENT
SUBSEQUENT PRENATAL VISIT
ASSESSMENT
INITIAL CLIENT HISTORY
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PERSONAL INFORMATION
OBSTETRIC HISTORY
GYNECOLOGIC HISTORY
CURRENT MEDICAL HISTORY
PAST MEDICAL HISTORY
FAMILY MEDICAL HISTORY
SOCIOCULTURAL HISTORY
INITIAL CLIENT HISTORY
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CONT.
OCCUPATIONAL HISTORY
PARTNER’S HISTORY
STRATEGIES FOR OBTAINING DATA
PRENATAL HIGH-RISK SCREENING
PERSONAL
INFORMATION
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NAME
AGE
OCCUPATION
MARITAL STATUS
EDUCATION LEVEL
RACE,ETHNIC GROUP
ADDRESS,PHONE NUMBER
PERSONAL
INFORMATION
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SUPPORT SYSTEM
CHILBIRTH PLANS
NEONATE PLANS
OBSTETRIC HISTORY
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TERMS
GRAVIDA-G
PARA-P
TPAL
GPTPAL
GTPAL
OBSTETRICAL HISTORY
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GPTPAL
ABORTIONS-WHEN IN
GESTATION.TYPE,COMPLICATIONS.
HX OF PREVIOUS PREGNANCIESGESTATION
LENGTH,COMPLICATIONS,OUTCOME
LABORLENGTH,COMPLICATIONS,OUTCOME
OBSTETRICAL HISTORY
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TYPE OF DELIVERYCOMPLICATIONS.OUTCOME
TYPE OF ANESTHESIACOMPLICATIONS
POSTPARTAL EVENTS
NEONATAL STATUS-WEIGHTS,APGAR
SCORES, COMPLICATIONS
CONT. OB HX
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BLOOD TYPE&RH (Was Rhogam given
if client is RH-negitive?)
CHILDBIRTH EDUCATION-type and
when
GYNECOLOGIC HISTORY
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PAP SMEAR
INFECTIONS
SURGERIES
MENARCHE
MENSTRUAL HISTORY
SEXUAL HISTORY
CONTRACEPTIVE USE
CURRENT MEDICAL
HISTORY
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WEIGHT-CURRENT & PREPREGNANT
HEIGHT
BMI
BLOOD-TYPE&RH
GENERAL HEALTH
NUTRITION
EXERCISE
CURRENT MEDICAL
HISTORY
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SUBSTANCE ABUSE/USE
MEDICATIONSOTC,HERBS,PRESCRIPTIONS
ALLERGIES
ENVIRONMENTAL FACTORS
CURRENT DISEASES OR CONDITIONS
IMMUNIZATIONS
CONT.CURRENT MED,HX.
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CLINCAL MANIFESTATIONS OF
PREGNANCY
ABNORMAL S/S
PAST MEDICAL HISTORY
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CHILDHOOD DISEASES
PAST DISEASES OR CONDITIONS- IE
STI’S,UTI’S,RHEUMATIC FEVER.
SURGERIES
BLEEDING PROBLEMS
TRANSFUSIONS
FAMILY MEDICAL
HISTORY
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HEALTH STATUS OF FAMILY
DISEASES &/OR CONDITIONS
MULTIPLE BIRTHS
CONGENITAL CONDITIONS
MENTAL ILLNESS
C/S
CAUSE OF DEATH OF FAMILY
SOCIOCULTURAL
HISTORY
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OCCUPATION
ED LEVEL
RELIGION
RACE,ETHNIC GROUP
AGE
BELIEFS & PRACTICESHEALTH,CHILDBIRTH, CHILDREARING
OCCUPATIONAL HISTORY
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OCCUPATION
WHAT IS DONE IN OCCUPATION?
ACTIVITIES
PHYSICAL DEMANDS
EXPOSURE TO ENVIRONMENTAL
FACTORS
BREAKS
PARTNER’S HISTORY
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NAME
AGE
HEALTH STATUS
SUBSTANCES USE
BLOOD TYPE & RH
OCCUPATION
ED LEVEL
PARTNER’S HISTORY
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FAMILY MEDICAL HX
CONGENITAL PROBLEMS
ENVIRONMENTAL FACTORS
ATTITUDE TOWARDS PREGNANCY
STRATEGIES FOR
OBTAINING DATA
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QUESTIONNAIRE
DIRECT INTERVIEW WITH CLIENT
EXPECTANT FATHER
PHYSICAL EXAMINATION
LABORATORY & DX TESTS
CLARIFY INFORMATION
ANSWER QUESTIONS
PRENATAL HIGH-RISK
SCREENING
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SOCIOECONOMIC FACTORS
ENVIRONMENTAL FACTORS
MEDICAL HISTORY
DAILY HABITS
SUBSTANCE USE
CLINICAL MANIFESTATIONSABNORMAL FOR GESTATION
HIGH RISK SCREENING
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ABUSE SCREENING
SCREEN FOR RISK FOR DVTs
INITIAL PRENATAL
ASSESSMENT
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PSYCHOSOCIAL-CULTURAL
ASSESSMENT
PHYSICAL ASSESSMENT
NUTRITIONAL ASSESSMENT
LEARNING NEEDS ASSESSMENT
PSYCHOSOCIALCULTURAL ASSESSMENT
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PSYCHOLOGICAL ASSESSMENT
SOCIOLOGICAL ASSESSMENT
CULTURAL ASSESSMENT
PSYCHOLOGICAL
ASSESSMENT
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HX OF MENTAL CONDITIONS
CURRENT MENTAL CONDITIONS
ABUSE SCREENING
DEPRESSION SCREENING
ANXIETY SCREENING
EMOTIONAL SUPPORT
ATTITUDE TOWARDS PREGNANCY
PSYCHOLOGICAL
ASSESSMENT
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CONCERNS
FEARS
SOCIOLOGIAL
ASSESSMENT
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INCOME LEVEL
LIVING CONDITIONS
FINICIAL SUPPORT
INSURNCE
MARITAL STATUS
ED LEVEL
FAMILY SIZE &LOCATION
CULTURAL ASSESSMENT
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RELIGION
BELIEFS AND PRACTICES-HEALTHILLNESS,CHILBIRTH,CHILDREARING,
ROLES,DIETARY,BLOOD PRODUCTS.
SPIRITUAL WELL-BEING
PARTNER’S BELIEF AND PRACTICES
WITH ABOVE TOPICS.
ETHNIC GROUP
PHYSICAL ASSESSMENT
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PREPARATION FOR THE
EXAMINATION
HEAD TO TOE EXAMINATION
GYNECLOGIC EXAMINATION
CLINICAL MANIFESTATIONS OF
PREGNANCY
DETERMINE OF DUE DATE
LABORATORY AND DX TESTS
PREPARATION FOR THE
EXAMINATION
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KNOW THE PROCEDURE-WHAT IS
GOING TO BE DONE,EQUIPMENT IS
READY.
ASSESS CLIENTS KNOWLEDGE OF
PROCEDURE
CONSENT IS GIVE
ASK QUESTIONS
ANSWER QUESTIONS
PREPARATION FOR
EXAMINATION
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ADDRESS CONCERNS AND FEARS.
EXPLAIN PROCEDURE.
SUPPORT PERSON
RELAXATION TECHNIQUES
CULTURAL ISSUES
BLADDER
ENVIRONMENT
HEAD TO TOE
EXAMINATION
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THIS MEANS EVERY SYSTEM.
COMPLETE EXAMINATION
GYNECOLOGICAL
EXAMINATION
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VAGINAL EXAMINATION
PELVIC MEASUREMENTS
FUNDAL HEIGHT
EXTERNAL GENITALS
PAP SMEAR
ULTRASOUND
UTERUS
BREASTS
CLINICAL
MANIFESTATIONS OF
PREGNANCY
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SUBJECTIVE (PRESUMPTIVE)
OBJECTIVE (PROBABLE)
DIAGNOSTIC(POSITIVE)
NORMAL VS ABNORMAL
DETERMINATION OF DUE
DATE
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LMP
NAGEL’S RULE
FUNDAL HEIGHT
QUICKENING
FETAL HEARTBEAT
DX TESTS-SONOGRAM
Easy Way to Determine
Due Date and Weeks
Gestations
FUNDAL MEASUREMENT
FUNDAL HEIGHT AND
WEEKS GESTATION
LABORATORY AND DX
TESTS
CBC
 UA
 PREGNANCY TESTS
 STI’S-RPR-VDRL-FTAABS,GONORRHEA,HIV,HEPB,GBS,
CHLAMYDIA,HERPES.
 BLOODTYPE&RH,ANTIBODIES(Indirect
COOMBS)
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LAB& DX TESTS
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RUBELLA TITER
PAP SMEAR
OTHER AS INDICATED
SUBSEQUENT PRENATAL
VISITS ASSESMENT
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FREQUENCY OF VISITS
PSYCHOSOCIAL ASSESSMENT
PHYSICAL ASSESSMENT
NUTRITIONAL ASSESSMENT
LEARNING NEEDS ASSESSMENT
FREQUENCY OF VISITS
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AS INDICATED BY CLIENT’S
CONDITION AND HISTORY
ROUTINE-INITIAL,ONCE A
MONTH,THEN TWICE A MONTH,THEN
EVERY WEEK.
SUBSEQUENT VISITS
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VS
WEIGHT
EDEMA
UTERINE SIZE
FHR
LAB-UA FOR PROTIEN
,GLUCOSE,OTHER
CONT.
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CLINICAL MANIFESTATIONS OF
PREGNANCY-NORMAL
WARNING SIGNS
CONCERNS
QUESTIONS
LEARNING NEEDS
PSYCHOLOGICAL
ASSESSMENT
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PSYCHOLOGIC STATUS
DEVELOPMENTAL STAGE OF
PREGNANCY
SEXUALITY DURING PREGNANCY
COPING
ATTITUDE
SUPPORT
PHYSICAL ASSESSMENT
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PHYSICAL EXAMINATION
DISCOMFORTS OF PREGNANCY
DANGER SIGNS
NUTRITIONAL
ASSESSMENT
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WEIGHT
HEIGHT
BMI
WEIGHT GAIN/LOSS
DIETARY HISTORY& INTAKE
CULTURAL FACTORS
PHYSICAL EXAMINATION
NUTRITIONAL
ASSESSMENT
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LIKES/DISLIKES
ALLERGIES-FOOD
LEARNING NEEDS
LEARNING NEEDS
ASSESSMENT
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HEALTH PROMOTION
PREGNANCYPHYSICAL&PSYCHOLOGICAL
ASPECTS,DISCOMFORTS.SELF-HELP
MEASURES
DANGER SIGNS
CHILDBIRTH
CHILDCARE
LEARNING NEEDS
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BIRTHPLAN
INCLUDE SUPPORT PERSON
RESOURCES
***PRECONCEPTION****
GENERAL PUBLIC
QUESTIONS
THANK YOU
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http://www.youtube.com/watch?v=9C
CnsQyWBEc&feature=related