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IntroductionIntroduction
http://www.youtube.com/watch?v=9kSJUznSXNU&feature=fvwrel
MATERNAL MATERNAL ASSESSMENTASSESSMENT
Developed by Developed by
D. Ann Currie R.N. ,M.S.N.D. Ann Currie R.N. ,M.S.N.
20122012
ANTEPARTAL NURSING ANTEPARTAL NURSING ASSESSMENTASSESSMENT INITIAL CLIENT HISTORYINITIAL CLIENT HISTORY INITIAL PRENATAL ASSESSMENTINITIAL PRENATAL ASSESSMENT SUBSEQUENT PRENATAL VISIT SUBSEQUENT PRENATAL VISIT
ASSESSMENTASSESSMENT
INITIAL CLIENT INITIAL CLIENT HISTORYHISTORY PERSONAL INFORMATIONPERSONAL INFORMATION OBSTETRIC HISTORYOBSTETRIC HISTORY GYNECOLOGIC HISTORYGYNECOLOGIC HISTORY CURRENT MEDICAL HISTORYCURRENT MEDICAL HISTORY PAST MEDICAL HISTORYPAST MEDICAL HISTORY FAMILY MEDICAL HISTORYFAMILY MEDICAL HISTORY SOCIOCULTURAL HISTORYSOCIOCULTURAL HISTORY
INITIAL CLIENT INITIAL CLIENT HISTORYHISTORY CONT.CONT. OCCUPATIONAL HISTORYOCCUPATIONAL HISTORY PARTNER’S HISTORYPARTNER’S HISTORY STRATEGIES FOR OBTAINING STRATEGIES FOR OBTAINING
DATADATA PRENATAL HIGH-RISK SCREENINGPRENATAL HIGH-RISK SCREENING
PERSONAL PERSONAL INFORMATIONINFORMATION NAMENAME AGEAGE OCCUPATIONOCCUPATION MARITAL STATUSMARITAL STATUS EDUCATION LEVELEDUCATION LEVEL RACE,ETHNIC GROUPRACE,ETHNIC GROUP ADDRESS,PHONE NUMBERADDRESS,PHONE NUMBER
PERSONAL PERSONAL INFORMATIONINFORMATION SUPPORT SYSTEMSUPPORT SYSTEM CHILBIRTH PLANSCHILBIRTH PLANS NEONATE PLANSNEONATE PLANS
OBSTETRIC HISTORYOBSTETRIC HISTORY
TERMSTERMS GRAVIDA-GGRAVIDA-G PARA-PPARA-P TPALTPAL GPTPALGPTPAL GTPALGTPAL
OBSTETRICAL HISTORYOBSTETRICAL HISTORY
GPTPALGPTPAL ABORTIONS-WHEN IN ABORTIONS-WHEN IN
GESTATION.TYPE,COMPLICATIONS.GESTATION.TYPE,COMPLICATIONS. HX OF PREVIOUS PREGNANCIES- HX OF PREVIOUS PREGNANCIES-
GESTATION GESTATION LENGTH,COMPLICATIONS,OUTCOMELENGTH,COMPLICATIONS,OUTCOME
LABOR-LABOR-LENGTH,COMPLICATIONS,OUTCOMELENGTH,COMPLICATIONS,OUTCOME
OBSTETRICAL HISTORYOBSTETRICAL HISTORY
TYPE OF DELIVERY-TYPE OF DELIVERY-COMPLICATIONS.OUTCOMECOMPLICATIONS.OUTCOME
TYPE OF ANESTHESIA-TYPE OF ANESTHESIA-COMPLICATIONSCOMPLICATIONS
POSTPARTAL EVENTSPOSTPARTAL EVENTS NEONATAL STATUS-NEONATAL STATUS-
WEIGHTS,APGAR SCORES, WEIGHTS,APGAR SCORES, COMPLICATIONSCOMPLICATIONS
CONT. OB HXCONT. OB HX
BLOOD TYPE&RH (Was Rhogam BLOOD TYPE&RH (Was Rhogam given if client is RH-negitive?)given if client is RH-negitive?)
CHILDBIRTH EDUCATION-type and CHILDBIRTH EDUCATION-type and whenwhen
GYNECOLOGIC GYNECOLOGIC HISTORYHISTORY PAP SMEARPAP SMEAR INFECTIONSINFECTIONS SURGERIESSURGERIES MENARCHEMENARCHE MENSTRUAL HISTORYMENSTRUAL HISTORY SEXUAL HISTORYSEXUAL HISTORY CONTRACEPTIVE USECONTRACEPTIVE USE
CURRENT MEDICAL CURRENT MEDICAL HISTORYHISTORY WEIGHT-CURRENT & PREPREGNANTWEIGHT-CURRENT & PREPREGNANT HEIGHTHEIGHT BMIBMI BLOOD-TYPE&RHBLOOD-TYPE&RH GENERAL HEALTHGENERAL HEALTH NUTRITIONNUTRITION EXERCISEEXERCISE
CURRENT MEDICAL CURRENT MEDICAL HISTORYHISTORY SUBSTANCE ABUSE/USESUBSTANCE ABUSE/USE MEDICATIONS-MEDICATIONS-
OTC,HERBS,PRESCRIPTIONSOTC,HERBS,PRESCRIPTIONS ALLERGIESALLERGIES ENVIRONMENTAL FACTORSENVIRONMENTAL FACTORS CURRENT DISEASES OR CURRENT DISEASES OR
CONDITIONSCONDITIONS IMMUNIZATIONSIMMUNIZATIONS
CONT.CURRENT CONT.CURRENT MED,HX.MED,HX. CLINCAL MANIFESTATIONS OF CLINCAL MANIFESTATIONS OF
PREGNANCYPREGNANCY ABNORMAL S/SABNORMAL S/S
PAST MEDICAL PAST MEDICAL HISTORYHISTORY CHILDHOOD DISEASESCHILDHOOD DISEASES PAST DISEASES OR CONDITIONS- PAST DISEASES OR CONDITIONS-
IE STI’S,UTI’S,RHEUMATIC FEVER.IE STI’S,UTI’S,RHEUMATIC FEVER. SURGERIESSURGERIES BLEEDING PROBLEMSBLEEDING PROBLEMS TRANSFUSIONSTRANSFUSIONS
FAMILY MEDICAL FAMILY MEDICAL HISTORYHISTORY HEALTH STATUS OF FAMILYHEALTH STATUS OF FAMILY DISEASES &/OR CONDITIONSDISEASES &/OR CONDITIONS MULTIPLE BIRTHSMULTIPLE BIRTHS CONGENITAL CONDITIONSCONGENITAL CONDITIONS MENTAL ILLNESSMENTAL ILLNESS C/SC/S CAUSE OF DEATH OF FAMILYCAUSE OF DEATH OF FAMILY
SOCIOCULTURAL SOCIOCULTURAL HISTORYHISTORY OCCUPATIONOCCUPATION ED LEVELED LEVEL RELIGIONRELIGION RACE,ETHNIC GROUPRACE,ETHNIC GROUP AGEAGE BELIEFS & PRACTICES-BELIEFS & PRACTICES-
HEALTH,CHILDBIRTH, HEALTH,CHILDBIRTH, CHILDREARINGCHILDREARING
OCCUPATIONAL OCCUPATIONAL HISTORYHISTORY OCCUPATIONOCCUPATION WHAT IS DONE IN OCCUPATION?WHAT IS DONE IN OCCUPATION? ACTIVITIESACTIVITIES PHYSICAL DEMANDSPHYSICAL DEMANDS EXPOSURE TO ENVIRONMENTAL EXPOSURE TO ENVIRONMENTAL
FACTORSFACTORS BREAKSBREAKS
PARTNER’S HISTORYPARTNER’S HISTORY
NAMENAME AGEAGE HEALTH STATUSHEALTH STATUS SUBSTANCES USESUBSTANCES USE BLOOD TYPE & RHBLOOD TYPE & RH OCCUPATIONOCCUPATION ED LEVELED LEVEL
PARTNER’S HISTORYPARTNER’S HISTORY
FAMILY MEDICAL HXFAMILY MEDICAL HX CONGENITAL PROBLEMSCONGENITAL PROBLEMS ENVIRONMENTAL FACTORSENVIRONMENTAL FACTORS ATTITUDE TOWARDS PREGNANCYATTITUDE TOWARDS PREGNANCY
STRATEGIES FOR STRATEGIES FOR OBTAINING DATAOBTAINING DATA QUESTIONNAIREQUESTIONNAIRE DIRECT INTERVIEW WITH CLIENTDIRECT INTERVIEW WITH CLIENT EXPECTANT FATHEREXPECTANT FATHER PHYSICAL EXAMINATIONPHYSICAL EXAMINATION LABORATORY & DX TESTSLABORATORY & DX TESTS CLARIFY INFORMATIONCLARIFY INFORMATION ANSWER QUESTIONSANSWER QUESTIONS
PRENATAL HIGH-RISK PRENATAL HIGH-RISK SCREENINGSCREENING SOCIOECONOMIC FACTORSSOCIOECONOMIC FACTORS ENVIRONMENTAL FACTORSENVIRONMENTAL FACTORS MEDICAL HISTORYMEDICAL HISTORY DAILY HABITSDAILY HABITS SUBSTANCE USE SUBSTANCE USE CLINICAL MANIFESTATIONS-CLINICAL MANIFESTATIONS-
ABNORMAL FOR GESTATIONABNORMAL FOR GESTATION
HIGH RISK SCREENINGHIGH RISK SCREENING
ABUSE SCREENINGABUSE SCREENING SCREEN FOR RISK FOR DVTsSCREEN FOR RISK FOR DVTs
INITIAL PRENATAL INITIAL PRENATAL ASSESSMENTASSESSMENT PSYCHOSOCIAL-CULTURAL PSYCHOSOCIAL-CULTURAL
ASSESSMENTASSESSMENT PHYSICAL ASSESSMENTPHYSICAL ASSESSMENT NUTRITIONAL ASSESSMENTNUTRITIONAL ASSESSMENT LEARNING NEEDS ASSESSMENTLEARNING NEEDS ASSESSMENT
PSYCHOSOCIAL-PSYCHOSOCIAL-CULTURAL CULTURAL ASSESSMENTASSESSMENT PSYCHOLOGICAL ASSESSMENTPSYCHOLOGICAL ASSESSMENT SOCIOLOGICAL ASSESSMENTSOCIOLOGICAL ASSESSMENT CULTURAL ASSESSMENTCULTURAL ASSESSMENT
PSYCHOLOGICAL PSYCHOLOGICAL ASSESSMENTASSESSMENT HX OF MENTAL CONDITIONSHX OF MENTAL CONDITIONS CURRENT MENTAL CONDITIONSCURRENT MENTAL CONDITIONS ABUSE SCREENINGABUSE SCREENING DEPRESSION SCREENINGDEPRESSION SCREENING ANXIETY SCREENINGANXIETY SCREENING EMOTIONAL SUPPORTEMOTIONAL SUPPORT ATTITUDE TOWARDS PREGNANCYATTITUDE TOWARDS PREGNANCY
PSYCHOLOGICAL PSYCHOLOGICAL ASSESSMENTASSESSMENT CONCERNSCONCERNS FEARSFEARS
SOCIOLOGIAL SOCIOLOGIAL ASSESSMENTASSESSMENT INCOME LEVELINCOME LEVEL LIVING CONDITIONSLIVING CONDITIONS FINICIAL SUPPORTFINICIAL SUPPORT INSURNCEINSURNCE MARITAL STATUSMARITAL STATUS ED LEVELED LEVEL FAMILY SIZE &LOCATIONFAMILY SIZE &LOCATION
CULTURAL CULTURAL ASSESSMENTASSESSMENT RELIGIONRELIGION BELIEFS AND PRACTICES-HEALTH-BELIEFS AND PRACTICES-HEALTH-
ILLNESS,CHILBIRTH,CHILDREARING, ILLNESS,CHILBIRTH,CHILDREARING, ROLES,DIETARY,BLOOD PRODUCTS.ROLES,DIETARY,BLOOD PRODUCTS.
SPIRITUAL WELL-BEINGSPIRITUAL WELL-BEING PARTNER’S BELIEF AND PRACTICES PARTNER’S BELIEF AND PRACTICES
WITH ABOVE TOPICS.WITH ABOVE TOPICS. ETHNIC GROUPETHNIC GROUP
PHYSICAL PHYSICAL ASSESSMENTASSESSMENT PREPARATION FOR THE PREPARATION FOR THE
EXAMINATIONEXAMINATION HEAD TO TOE EXAMINATIONHEAD TO TOE EXAMINATION GYNECLOGIC EXAMINATIONGYNECLOGIC EXAMINATION CLINICAL MANIFESTATIONS OF CLINICAL MANIFESTATIONS OF
PREGNANCYPREGNANCY DETERMINE OF DUE DATEDETERMINE OF DUE DATE LABORATORY AND DX TESTSLABORATORY AND DX TESTS
PREPARATION FOR PREPARATION FOR THE EXAMINATIONTHE EXAMINATION KNOW THE PROCEDURE-WHAT IS KNOW THE PROCEDURE-WHAT IS
GOING TO BE DONE,EQUIPMENT IS GOING TO BE DONE,EQUIPMENT IS READY.READY.
ASSESS CLIENTS KNOWLEDGE OF ASSESS CLIENTS KNOWLEDGE OF PROCEDUREPROCEDURE
CONSENT IS GIVECONSENT IS GIVE ASK QUESTIONSASK QUESTIONS ANSWER QUESTIONSANSWER QUESTIONS
PREPARATION FOR PREPARATION FOR EXAMINATIONEXAMINATION ADDRESS CONCERNS AND FEARS. ADDRESS CONCERNS AND FEARS. EXPLAIN PROCEDURE.EXPLAIN PROCEDURE. SUPPORT PERSONSUPPORT PERSON RELAXATION TECHNIQUESRELAXATION TECHNIQUES CULTURAL ISSUESCULTURAL ISSUES BLADDERBLADDER ENVIRONMENTENVIRONMENT
HEAD TO TOE HEAD TO TOE EXAMINATIONEXAMINATION THIS MEANS EVERY SYSTEM.THIS MEANS EVERY SYSTEM. COMPLETE EXAMINATIONCOMPLETE EXAMINATION
GYNECOLOGICAL GYNECOLOGICAL EXAMINATIONEXAMINATION VAGINAL EXAMINATIONVAGINAL EXAMINATION PELVIC MEASUREMENTSPELVIC MEASUREMENTS FUNDAL HEIGHTFUNDAL HEIGHT EXTERNAL GENITALSEXTERNAL GENITALS PAP SMEARPAP SMEAR ULTRASOUNDULTRASOUND UTERUSUTERUS BREASTSBREASTS
CLINICAL CLINICAL MANIFESTATIONS OF MANIFESTATIONS OF PREGNANCYPREGNANCY SUBJECTIVE (PRESUMPTIVE)SUBJECTIVE (PRESUMPTIVE) OBJECTIVE (PROBABLE)OBJECTIVE (PROBABLE) DIAGNOSTIC(POSITIVE)DIAGNOSTIC(POSITIVE) NORMAL VS ABNORMALNORMAL VS ABNORMAL
DETERMINATION OF DETERMINATION OF DUE DATEDUE DATE LMPLMP NAGEL’S RULENAGEL’S RULE FUNDAL HEIGHTFUNDAL HEIGHT QUICKENINGQUICKENING FETAL HEARTBEATFETAL HEARTBEAT DX TESTS-SONOGRAMDX TESTS-SONOGRAM
Easy Way to Easy Way to Determine Due Date Determine Due Date and Weeks Gestationsand Weeks Gestations
FUNDAL FUNDAL MEASUREMENTMEASUREMENT
FUNDAL HEIGHT AND FUNDAL HEIGHT AND WEEKS GESTATIONWEEKS GESTATION
LABORATORY AND DX LABORATORY AND DX TESTSTESTS CBCCBC UAUA PREGNANCY TESTSPREGNANCY TESTS STI’S-RPR-VDRL-FTA-STI’S-RPR-VDRL-FTA-
ABS,GONORRHEA,HIV,HEPB,GBS, ABS,GONORRHEA,HIV,HEPB,GBS, CHLAMYDIA,HERPES.CHLAMYDIA,HERPES.
BLOOD- BLOOD-
TYPE&RH,ANTIBODIES(Indirect TYPE&RH,ANTIBODIES(Indirect COOMBS)COOMBS)
LAB& DX TESTSLAB& DX TESTS
RUBELLA TITERRUBELLA TITER PAP SMEARPAP SMEAR OTHER AS INDICATEDOTHER AS INDICATED
SUBSEQUENT SUBSEQUENT PRENATAL VISITS PRENATAL VISITS ASSESMENTASSESMENT FREQUENCY OF VISITSFREQUENCY OF VISITS PSYCHOSOCIAL ASSESSMENTPSYCHOSOCIAL ASSESSMENT PHYSICAL ASSESSMENTPHYSICAL ASSESSMENT NUTRITIONAL ASSESSMENTNUTRITIONAL ASSESSMENT LEARNING NEEDS ASSESSMENTLEARNING NEEDS ASSESSMENT
FREQUENCY OF VISITSFREQUENCY OF VISITS
AS INDICATED BY CLIENT’S AS INDICATED BY CLIENT’S CONDITION AND HISTORYCONDITION AND HISTORY
ROUTINE-INITIAL,ONCE A ROUTINE-INITIAL,ONCE A MONTH,THEN TWICE A MONTH,THEN TWICE A MONTH,THEN EVERY WEEK.MONTH,THEN EVERY WEEK.
SUBSEQUENT VISITSSUBSEQUENT VISITS
VSVS WEIGHTWEIGHT EDEMAEDEMA UTERINE SIZE UTERINE SIZE FHRFHR LAB-UA FOR LAB-UA FOR
PROTIEN ,GLUCOSE,OTHERPROTIEN ,GLUCOSE,OTHER
CONT.CONT.
CLINICAL MANIFESTATIONS OF CLINICAL MANIFESTATIONS OF PREGNANCY-NORMALPREGNANCY-NORMAL
WARNING SIGNSWARNING SIGNS CONCERNSCONCERNS QUESTIONSQUESTIONS LEARNING NEEDSLEARNING NEEDS
PSYCHOLOGICAL PSYCHOLOGICAL ASSESSMENTASSESSMENT PSYCHOLOGIC STATUSPSYCHOLOGIC STATUS DEVELOPMENTAL STAGE OF DEVELOPMENTAL STAGE OF
PREGNANCYPREGNANCY SEXUALITY DURING PREGNANCYSEXUALITY DURING PREGNANCY COPINGCOPING ATTITUDEATTITUDE SUPPORTSUPPORT
PHYSICAL PHYSICAL ASSESSMENTASSESSMENT PHYSICAL EXAMINATIONPHYSICAL EXAMINATION DISCOMFORTS OF PREGNANCYDISCOMFORTS OF PREGNANCY DANGER SIGNSDANGER SIGNS
NUTRITIONAL NUTRITIONAL ASSESSMENTASSESSMENT WEIGHTWEIGHT HEIGHTHEIGHT BMIBMI WEIGHT GAIN/LOSSWEIGHT GAIN/LOSS DIETARY HISTORY& INTAKEDIETARY HISTORY& INTAKE CULTURAL FACTORSCULTURAL FACTORS PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
NUTRITIONAL NUTRITIONAL ASSESSMENTASSESSMENT LIKES/DISLIKESLIKES/DISLIKES ALLERGIES-FOODALLERGIES-FOOD LEARNING NEEDSLEARNING NEEDS
LEARNING NEEDS LEARNING NEEDS ASSESSMENTASSESSMENT HEALTH PROMOTIONHEALTH PROMOTION PREGNANCY-PREGNANCY-
PHYSICAL&PSYCHOLOGICAL PHYSICAL&PSYCHOLOGICAL ASPECTS,DISCOMFORTS.SELF-HELP ASPECTS,DISCOMFORTS.SELF-HELP MEASURESMEASURES
DANGER SIGNSDANGER SIGNS CHILDBIRTHCHILDBIRTH CHILDCARECHILDCARE
LEARNING NEEDSLEARNING NEEDS
BIRTHPLANBIRTHPLAN INCLUDE SUPPORT PERSONINCLUDE SUPPORT PERSON RESOURCESRESOURCES ***PRECONCEPTION*******PRECONCEPTION**** GENERAL PUBLICGENERAL PUBLIC
QUESTIONSQUESTIONS
THANK YOUTHANK YOU
http://www.youtube.com/watch?v=9CCnsQyWBEc&feature=related