MATERNAL MATERNAL ASSESSMENTASSESSMENT

Developed by Developed by

D. Ann Currie,R.N. ,M.S.N.D. Ann Currie,R.N. ,M.S.N.

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 USESUBSTANCE USE CLINICAL MANIFESTATIONS-CLINICAL MANIFESTATIONS-

ABNORMAL FOR GESTATIONABNORMAL FOR GESTATION

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