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Introduction

http://www.youtube.com/watch?v
=9kSJUznSXNU&feature=fvwrel
MATERNAL
ASSESSMENT
Developed by
D. Ann Currie R.N. ,M.S.N.
2012
ANTEPARTAL NURSING
ASSESSMENT
INITIAL CLIENT HISTORY
INITIAL PRENATAL ASSESSMENT
SUBSEQUENT PRENATAL VISIT
ASSESSMENT
INITIAL CLIENT
HISTORY
PERSONAL INFORMATION
OBSTETRIC HISTORY
GYNECOLOGIC HISTORY
CURRENT MEDICAL HISTORY
PAST MEDICAL HISTORY
FAMILY MEDICAL HISTORY
SOCIOCULTURAL HISTORY
INITIAL CLIENT
HISTORY
CONT.
OCCUPATIONAL HISTORY
PARTNERS HISTORY
STRATEGIES FOR OBTAINING DATA
PRENATAL HIGH-RISK SCREENING
PERSONAL
INFORMATION
NAME
AGE
OCCUPATION
MARITAL STATUS
EDUCATION LEVEL
RACE,ETHNIC GROUP
ADDRESS,PHONE NUMBER
PERSONAL
INFORMATION
SUPPORT SYSTEM
CHILBIRTH PLANS
NEONATE PLANS
OBSTETRIC HISTORY
TERMS
GRAVIDA-G
PARA-P
TPAL
GPTPAL
GTPAL
OBSTETRICAL HISTORY
GPTPAL
ABORTIONS-WHEN IN
GESTATION.TYPE,COMPLICATIONS.
HX OF PREVIOUS PREGNANCIES-
GESTATION
LENGTH,COMPLICATIONS,OUTCOME
LABOR-
LENGTH,COMPLICATIONS,OUTCOME
OBSTETRICAL HISTORY
TYPE OF DELIVERY-
COMPLICATIONS.OUTCOME
TYPE OF ANESTHESIA-
COMPLICATIONS
POSTPARTAL EVENTS
NEONATAL STATUS-
WEIGHTS,APGAR SCORES,
COMPLICATIONS
CONT. OB HX
BLOOD TYPE&RH (Was Rhogam
given if client is RH-negitive?)
CHILDBIRTH EDUCATION-type and
when
GYNECOLOGIC
HISTORY
PAP SMEAR
INFECTIONS
SURGERIES
MENARCHE
MENSTRUAL HISTORY
SEXUAL HISTORY
CONTRACEPTIVE USE
CURRENT MEDICAL
HISTORY
WEIGHT-CURRENT & PREPREGNANT
HEIGHT
BMI
BLOOD-TYPE&RH
GENERAL HEALTH
NUTRITION
EXERCISE
CURRENT MEDICAL
HISTORY
SUBSTANCE ABUSE/USE
MEDICATIONS-
OTC,HERBS,PRESCRIPTIONS
ALLERGIES
ENVIRONMENTAL FACTORS
CURRENT DISEASES OR CONDITIONS
IMMUNIZATIONS
CONT.CURRENT
MED,HX.
CLINCAL MANIFESTATIONS OF
PREGNANCY
ABNORMAL S/S
PAST MEDICAL
HISTORY
CHILDHOOD DISEASES
PAST DISEASES OR CONDITIONS-
IE STIS,UTIS,RHEUMATIC FEVER.
SURGERIES
BLEEDING PROBLEMS
TRANSFUSIONS
FAMILY MEDICAL
HISTORY
HEALTH STATUS OF FAMILY
DISEASES &/OR CONDITIONS
MULTIPLE BIRTHS
CONGENITAL CONDITIONS
MENTAL ILLNESS
C/S
CAUSE OF DEATH OF FAMILY
SOCIOCULTURAL
HISTORY
OCCUPATION
ED LEVEL
RELIGION
RACE,ETHNIC GROUP
AGE
BELIEFS & PRACTICES-
HEALTH,CHILDBIRTH, CHILDREARING
OCCUPATIONAL
HISTORY
OCCUPATION
WHAT IS DONE IN OCCUPATION?
ACTIVITIES
PHYSICAL DEMANDS
EXPOSURE TO ENVIRONMENTAL
FACTORS
BREAKS
PARTNERS HISTORY
NAME
AGE
HEALTH STATUS
SUBSTANCES USE
BLOOD TYPE & RH
OCCUPATION
ED LEVEL
PARTNERS HISTORY
FAMILY MEDICAL HX
CONGENITAL PROBLEMS
ENVIRONMENTAL FACTORS
ATTITUDE TOWARDS PREGNANCY
STRATEGIES FOR
OBTAINING DATA
QUESTIONNAIRE
DIRECT INTERVIEW WITH CLIENT
EXPECTANT FATHER
PHYSICAL EXAMINATION
LABORATORY & DX TESTS
CLARIFY INFORMATION
ANSWER QUESTIONS
PRENATAL HIGH-RISK
SCREENING
SOCIOECONOMIC FACTORS
ENVIRONMENTAL FACTORS
MEDICAL HISTORY
DAILY HABITS
SUBSTANCE USE
CLINICAL MANIFESTATIONS-
ABNORMAL FOR GESTATION
HIGH RISK SCREENING
ABUSE SCREENING
SCREEN FOR RISK FOR DVTs
INITIAL PRENATAL
ASSESSMENT
PSYCHOSOCIAL-CULTURAL
ASSESSMENT
PHYSICAL ASSESSMENT
NUTRITIONAL ASSESSMENT
LEARNING NEEDS ASSESSMENT
PSYCHOSOCIAL-
CULTURAL
ASSESSMENT
PSYCHOLOGICAL ASSESSMENT

SOCIOLOGICAL ASSESSMENT
CULTURAL ASSESSMENT
PSYCHOLOGICAL
ASSESSMENT
HX OF MENTAL CONDITIONS
CURRENT MENTAL CONDITIONS
ABUSE SCREENING
DEPRESSION SCREENING
ANXIETY SCREENING
EMOTIONAL SUPPORT
ATTITUDE TOWARDS PREGNANCY
PSYCHOLOGICAL
ASSESSMENT
CONCERNS
FEARS
SOCIOLOGIAL
ASSESSMENT
INCOME LEVEL
LIVING CONDITIONS
FINICIAL SUPPORT
INSURNCE
MARITAL STATUS
ED LEVEL
FAMILY SIZE &LOCATION
CULTURAL
ASSESSMENT
RELIGION
BELIEFS AND PRACTICES-HEALTH-
ILLNESS,CHILBIRTH,CHILDREARING,
ROLES,DIETARY,BLOOD PRODUCTS.
SPIRITUAL WELL-BEING
PARTNERS BELIEF AND PRACTICES
WITH ABOVE TOPICS.
ETHNIC GROUP
PHYSICAL
ASSESSMENT
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
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
ADDRESS CONCERNS AND FEARS.
EXPLAIN PROCEDURE.
SUPPORT PERSON
RELAXATION TECHNIQUES
CULTURAL ISSUES
BLADDER
ENVIRONMENT
HEAD TO TOE
EXAMINATION
THIS MEANS EVERY SYSTEM.
COMPLETE EXAMINATION
GYNECOLOGICAL
EXAMINATION
VAGINAL EXAMINATION
PELVIC MEASUREMENTS
FUNDAL HEIGHT
EXTERNAL GENITALS
PAP SMEAR
ULTRASOUND
UTERUS
BREASTS
CLINICAL
MANIFESTATIONS OF
PREGNANCY
SUBJECTIVE (PRESUMPTIVE)

OBJECTIVE (PROBABLE)
DIAGNOSTIC(POSITIVE)
NORMAL VS ABNORMAL
DETERMINATION OF
DUE DATE
LMP
NAGELS 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

STIS-RPR-VDRL-FTA-

ABS,GONORRHEA,HIV,HEPB,GBS,
CHLAMYDIA,HERPES.
BLOOD-

TYPE&RH,ANTIBODIES(Indirect
COOMBS)
LAB& DX TESTS
RUBELLA TITER
PAP SMEAR
OTHER AS INDICATED
SUBSEQUENT
PRENATAL VISITS
ASSESMENT
FREQUENCY OF VISITS

PSYCHOSOCIAL ASSESSMENT
PHYSICAL ASSESSMENT
NUTRITIONAL ASSESSMENT
LEARNING NEEDS ASSESSMENT
FREQUENCY OF VISITS
AS INDICATED BY CLIENTS
CONDITION AND HISTORY
ROUTINE-INITIAL,ONCE A
MONTH,THEN TWICE A
MONTH,THEN EVERY WEEK.
SUBSEQUENT VISITS
VS
WEIGHT
EDEMA
UTERINE SIZE
FHR
LAB-UA FOR PROTIEN
,GLUCOSE,OTHER
CONT.
CLINICAL MANIFESTATIONS OF
PREGNANCY-NORMAL
WARNING SIGNS
CONCERNS
QUESTIONS
LEARNING NEEDS
PSYCHOLOGICAL
ASSESSMENT
PSYCHOLOGIC STATUS
DEVELOPMENTAL STAGE OF
PREGNANCY
SEXUALITY DURING PREGNANCY
COPING
ATTITUDE
SUPPORT
PHYSICAL
ASSESSMENT
PHYSICAL EXAMINATION
DISCOMFORTS OF PREGNANCY
DANGER SIGNS
NUTRITIONAL
ASSESSMENT
WEIGHT
HEIGHT
BMI
WEIGHT GAIN/LOSS
DIETARY HISTORY& INTAKE
CULTURAL FACTORS
PHYSICAL EXAMINATION
NUTRITIONAL
ASSESSMENT
LIKES/DISLIKES
ALLERGIES-FOOD
LEARNING NEEDS
LEARNING NEEDS
ASSESSMENT
HEALTH PROMOTION
PREGNANCY-
PHYSICAL&PSYCHOLOGICAL
ASPECTS,DISCOMFORTS.SELF-HELP
MEASURES
DANGER SIGNS
CHILDBIRTH
CHILDCARE
LEARNING NEEDS
BIRTHPLAN
INCLUDE SUPPORT PERSON
RESOURCES
***PRECONCEPTION****
GENERAL PUBLIC
QUESTIONS
THANK YOU
http://www.youtube.com/watch?
v=9CCnsQyWBEc&feature=related

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