Admission Assessment of the Pregnant Woman

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Admission Assessment of the

Pregnant Woman

Evelyn M. Hickson, RN, MSN, CNS, WCC

Objectives

Identify 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.

Review of Prenatal Records

Review office reports, including

Obstetrical history

Personal medical history

Family history

Social history

Note any areas of concern identified by the care provider

Prenatal Labs

Blood type and antibody screen

Rubella immunity

GBS culture

HSV

HIV

Hepatitis B

VDRL/RPR

Quad screen

Glucose tolerance testing

OB History: Current Pregnancy

Maternal age

EDC

Dating criteria

How early did she start prenatal care?

Gestation

Current complications

GTPAL

Gravidity

Term births

Preterm (<37 wk) births

Abortions (elective, therapeutic or spontaneous)

Living children

OB History: Multiparous Patients

Length of previous labors, infant birth weight, gestational age at delivery

History of preterm labor or delivery

Previous operative delivery

Previous stillbirth

History of postpartum hemorrhage or postpartum depression

Social History

Marital status or available family support

CPS or other alerts

Social/economic/educational concerns

Physical/mental challenges

Referral to social services

Language barriers

Religious or cultural practices

Prioritizing the Patient Interview

Sometimes the urgency of the situation dictates the order in which one proceeds with a patient interview, such as:

Imminent delivery

Unstable maternal condition

(Unconscious, bleeding, seizing, etc)

Category 3 fetal tracing

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.

Patient Interview (cont.)

Current medications

Dose, route, last taken

Allergies and reactions

When the patient last ate or drank

(including what was eaten or drunk)

Recent SVE

Complications with current or previous pregnancy

Is the patient experiencing…

Nausea or vomiting

Frequency or burning with urination

Epigastric pain

Headaches

Visual disturbances

Physical Assessment

Leopold’s Maneuvers

EFM

Orient patient to monitors and basic strip interpretation

Physical Assessment

Vital signs (full set)

Urine dip

Physical exam including:

Edema

DTRs and Clonus

Breath sounds if patient presents with respiratory symptoms

SVE

unless contraindicated

Labor Assessment

Time contractions started

Frequency, duration, and regularity of contractions

Palpation of maternal abdomen during and between contractions

Fetal movement

Pain assessment, including location and type of pain

Herbs/Foods That Increase

Uterine Activity

Bitter Melon

Castor bean or castor oil

Chamomile tea

Cinnamon (spice tea)

Garlic

Ginger

Goldenseal

Pomegranate

Red raspberry leaf tea

Suspected Rupture of Membranes

Intercourse in last 12-24 hours

Time possible SROM occurred

Color, amount, and smell of fluid

Testing of vaginal discharge for presence of amniotic fluid

Substance Use and Abuse

Warning signs of drug abuse:

Noncompliance with prenatal care

– late entry or no prenatal care

Poor nutrition

–due to adolescence, obesity, low socioeconomic status

Current or previous history of encounters with law enforcement

Marital & family disputes

Intrapartum signs of substance abuse

Unexplained IUGR

3 rd trimester stillbirth

Unexpected preterm birth

Placental abruption in a woman without hypertensive disorders.

Informed consent

for testing

Social service consult, CPS, drug treatment

Domestic Violence

Majority 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.

Pregnancy and Domestic Violence

Signs of domestic violence in the pregnant patient include:

 unwanted pregnancy late entry into prenatal care

 missed appointments substance abuse or use poor weight gain and nutrition multiple, repeated somatic complaints.

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

Promptly Notify Care Provider if:

Vaginal bleeding

Acute abdominal pain

Temperature of 100.4 F or higher

Preterm labor

Preterm rupture of membranes

Hypertension

Non-reassuring fetal heart rate pattern

SBAR Communication

Best method to speak to providers

Gives you a standard list of things you need to be prepared to discuss with them

Be concise and factual

Do not use “touchy-feely” language

SBAR Communication

S

ituation

What is going on with the patient?

B

ackground

What is the clinical context?

A

ssessment

What do I think the problem is?

R

ecommendation

What would I do to correct it?

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 chart

List of current medications, allergies, whether IV was placed and labs drawn

Most recent vital signs

Reporting lab results: provide the date and time test was done and results of previous labs for comparison

SBAR: Situation

What is the situation you are calling about?

Identify self, unit, patient, room number

State who the patient’s doctor has been for the pregnancy

Briefly state the problem, what is it, when it happened or started, and how severe.

SBAR: Background

Pertinent background information related to the situation could include:

Gestation, GTPAL, age, previously identified risk factors

List of current medications, allergies, labs

Most recent vital signs

Clinical information

SBAR: Assessment and

Recommendation

What is your assessment of the situation?

What is your recommendation or expectation?

Admission for labor

Patient needs to be seen

now

Patient needs antibiotics for UTI, etc.

Document the care provider notification, orders received, changes in patient condition, and plan.

Guidelines for Communication with

Physicians Using SBAR

Use the following according to provider preference.

Direct page

Call service

During weekdays, the office directly

On weekends and after hours during the week, home phone

Cell 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.

References

Guidelines for Perinatal Care, (6 th 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.

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