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Comprehensive Maternal Assessment: Initial Prenatal Evaluation for New Clients

This guide covers the critical components of maternal assessment before and during pregnancy. Developed by D. Ann Currie, this resource details strategies for obtaining initial client history, including personal, obstetric, gynecologic, medical, family, and sociocultural data. It also addresses prenatal high-risk screening, psychosocial assessments, and the physical examination process. Aimed at healthcare professionals, the content provides a structured approach to ensure thorough evaluations that support healthy pregnancy outcomes.

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Comprehensive Maternal Assessment: Initial Prenatal Evaluation for New Clients

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  1. Introduction • http://www.youtube.com/watch?v=9kSJUznSXNU&feature=fvwrel

  2. MATERNAL ASSESSMENT Developed by D. Ann Currie R.N. ,M.S.N. 2012

  3. ANTEPARTAL NURSING ASSESSMENT • INITIAL CLIENT HISTORY • INITIAL PRENATAL ASSESSMENT • SUBSEQUENT PRENATAL VISIT ASSESSMENT

  4. INITIAL CLIENT HISTORY • PERSONAL INFORMATION • OBSTETRIC HISTORY • GYNECOLOGIC HISTORY • CURRENT MEDICAL HISTORY • PAST MEDICAL HISTORY • FAMILY MEDICAL HISTORY • SOCIOCULTURAL HISTORY

  5. INITIAL CLIENT HISTORY • CONT. • OCCUPATIONAL HISTORY • PARTNER’S HISTORY • STRATEGIES FOR OBTAINING DATA • PRENATAL HIGH-RISK SCREENING

  6. PERSONAL INFORMATION • NAME • AGE • OCCUPATION • MARITAL STATUS • EDUCATION LEVEL • RACE,ETHNIC GROUP • ADDRESS,PHONE NUMBER

  7. PERSONAL INFORMATION • SUPPORT SYSTEM • CHILBIRTH PLANS • NEONATE PLANS

  8. OBSTETRIC HISTORY • TERMS • GRAVIDA-G • PARA-P • TPAL • GPTPAL • GTPAL

  9. OBSTETRICAL HISTORY • GPTPAL • ABORTIONS-WHEN IN GESTATION.TYPE,COMPLICATIONS. • HX OF PREVIOUS PREGNANCIES- GESTATION LENGTH,COMPLICATIONS,OUTCOME • LABOR-LENGTH,COMPLICATIONS,OUTCOME

  10. OBSTETRICAL HISTORY • TYPE OF DELIVERY-COMPLICATIONS.OUTCOME • TYPE OF ANESTHESIA-COMPLICATIONS • POSTPARTAL EVENTS • NEONATAL STATUS-WEIGHTS,APGAR SCORES, COMPLICATIONS

  11. CONT. OB HX • BLOOD TYPE&RH (Was Rhogam given if client is RH-negitive?) • CHILDBIRTH EDUCATION-type and when

  12. GYNECOLOGIC HISTORY • PAP SMEAR • INFECTIONS • SURGERIES • MENARCHE • MENSTRUAL HISTORY • SEXUAL HISTORY • CONTRACEPTIVE USE

  13. CURRENT MEDICAL HISTORY • WEIGHT-CURRENT & PREPREGNANT • HEIGHT • BMI • BLOOD-TYPE&RH • GENERAL HEALTH • NUTRITION • EXERCISE

  14. CURRENT MEDICAL HISTORY • SUBSTANCE ABUSE/USE • MEDICATIONS-OTC,HERBS,PRESCRIPTIONS • ALLERGIES • ENVIRONMENTAL FACTORS • CURRENT DISEASES OR CONDITIONS • IMMUNIZATIONS

  15. CONT.CURRENT MED,HX. • CLINCAL MANIFESTATIONS OF PREGNANCY • ABNORMAL S/S

  16. PAST MEDICAL HISTORY • CHILDHOOD DISEASES • PAST DISEASES OR CONDITIONS- IE STI’S,UTI’S,RHEUMATIC FEVER. • SURGERIES • BLEEDING PROBLEMS • TRANSFUSIONS

  17. FAMILY MEDICAL HISTORY • HEALTH STATUS OF FAMILY • DISEASES &/OR CONDITIONS • MULTIPLE BIRTHS • CONGENITAL CONDITIONS • MENTAL ILLNESS • C/S • CAUSE OF DEATH OF FAMILY

  18. SOCIOCULTURAL HISTORY • OCCUPATION • ED LEVEL • RELIGION • RACE,ETHNIC GROUP • AGE • BELIEFS & PRACTICES-HEALTH,CHILDBIRTH, CHILDREARING

  19. OCCUPATIONAL HISTORY • OCCUPATION • WHAT IS DONE IN OCCUPATION? • ACTIVITIES • PHYSICAL DEMANDS • EXPOSURE TO ENVIRONMENTAL FACTORS • BREAKS

  20. PARTNER’S HISTORY • NAME • AGE • HEALTH STATUS • SUBSTANCES USE • BLOOD TYPE & RH • OCCUPATION • ED LEVEL

  21. PARTNER’S HISTORY • FAMILY MEDICAL HX • CONGENITAL PROBLEMS • ENVIRONMENTAL FACTORS • ATTITUDE TOWARDS PREGNANCY

  22. STRATEGIES FOR OBTAINING DATA • QUESTIONNAIRE • DIRECT INTERVIEW WITH CLIENT • EXPECTANT FATHER • PHYSICAL EXAMINATION • LABORATORY & DX TESTS • CLARIFY INFORMATION • ANSWER QUESTIONS

  23. PRENATAL HIGH-RISK SCREENING • SOCIOECONOMIC FACTORS • ENVIRONMENTAL FACTORS • MEDICAL HISTORY • DAILY HABITS • SUBSTANCE USE • CLINICAL MANIFESTATIONS-ABNORMAL FOR GESTATION

  24. HIGH RISK SCREENING • ABUSE SCREENING • SCREEN FOR RISK FOR DVTs

  25. INITIAL PRENATAL ASSESSMENT • PSYCHOSOCIAL-CULTURAL ASSESSMENT • PHYSICAL ASSESSMENT • NUTRITIONAL ASSESSMENT • LEARNING NEEDS ASSESSMENT

  26. PSYCHOSOCIAL-CULTURAL ASSESSMENT • PSYCHOLOGICAL ASSESSMENT • SOCIOLOGICAL ASSESSMENT • CULTURAL ASSESSMENT

  27. PSYCHOLOGICAL ASSESSMENT • HX OF MENTAL CONDITIONS • CURRENT MENTAL CONDITIONS • ABUSE SCREENING • DEPRESSION SCREENING • ANXIETY SCREENING • EMOTIONAL SUPPORT • ATTITUDE TOWARDS PREGNANCY

  28. PSYCHOLOGICAL ASSESSMENT • CONCERNS • FEARS

  29. SOCIOLOGIAL ASSESSMENT • INCOME LEVEL • LIVING CONDITIONS • FINICIAL SUPPORT • INSURNCE • MARITAL STATUS • ED LEVEL • FAMILY SIZE &LOCATION

  30. CULTURAL ASSESSMENT • RELIGION • BELIEFS AND PRACTICES-HEALTH-ILLNESS,CHILBIRTH,CHILDREARING, ROLES,DIETARY,BLOOD PRODUCTS. • SPIRITUAL WELL-BEING • PARTNER’S BELIEF AND PRACTICES WITH ABOVE TOPICS. • ETHNIC GROUP

  31. PHYSICAL ASSESSMENT • PREPARATION FOR THE EXAMINATION • HEAD TO TOE EXAMINATION • GYNECLOGIC EXAMINATION • CLINICAL MANIFESTATIONS OF PREGNANCY • DETERMINE OF DUE DATE • LABORATORY AND DX TESTS

  32. 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

  33. PREPARATION FOR EXAMINATION • ADDRESS CONCERNS AND FEARS. • EXPLAIN PROCEDURE. • SUPPORT PERSON • RELAXATION TECHNIQUES • CULTURAL ISSUES • BLADDER • ENVIRONMENT

  34. HEAD TO TOE EXAMINATION • THIS MEANS EVERY SYSTEM. • COMPLETE EXAMINATION

  35. GYNECOLOGICAL EXAMINATION • VAGINAL EXAMINATION • PELVIC MEASUREMENTS • FUNDAL HEIGHT • EXTERNAL GENITALS • PAP SMEAR • ULTRASOUND • UTERUS • BREASTS

  36. CLINICAL MANIFESTATIONS OF PREGNANCY • SUBJECTIVE (PRESUMPTIVE) • OBJECTIVE (PROBABLE) • DIAGNOSTIC(POSITIVE) • NORMAL VS ABNORMAL

  37. DETERMINATION OF DUE DATE • LMP • NAGEL’S RULE • FUNDAL HEIGHT • QUICKENING • FETAL HEARTBEAT • DX TESTS-SONOGRAM

  38. Easy Way to Determine Due Date and Weeks Gestations

  39. FUNDAL MEASUREMENT

  40. FUNDAL HEIGHT AND WEEKS GESTATION

  41. LABORATORY AND DX TESTS • CBC • UA • PREGNANCY TESTS • STI’S-RPR-VDRL-FTA-ABS,GONORRHEA,HIV,HEPB,GBS, CHLAMYDIA,HERPES. • BLOOD- TYPE&RH,ANTIBODIES(Indirect COOMBS)

  42. LAB& DX TESTS • RUBELLA TITER • PAP SMEAR • OTHER AS INDICATED

  43. SUBSEQUENT PRENATAL VISITS ASSESMENT • FREQUENCY OF VISITS • PSYCHOSOCIAL ASSESSMENT • PHYSICAL ASSESSMENT • NUTRITIONAL ASSESSMENT • LEARNING NEEDS ASSESSMENT

  44. FREQUENCY OF VISITS • AS INDICATED BY CLIENT’S CONDITION AND HISTORY • ROUTINE-INITIAL,ONCE A MONTH,THEN TWICE A MONTH,THEN EVERY WEEK.

  45. SUBSEQUENT VISITS • VS • WEIGHT • EDEMA • UTERINE SIZE • FHR • LAB-UA FOR PROTIEN ,GLUCOSE,OTHER

  46. CONT. • CLINICAL MANIFESTATIONS OF PREGNANCY-NORMAL • WARNING SIGNS • CONCERNS • QUESTIONS • LEARNING NEEDS

  47. PSYCHOLOGICAL ASSESSMENT • PSYCHOLOGIC STATUS • DEVELOPMENTAL STAGE OF PREGNANCY • SEXUALITY DURING PREGNANCY • COPING • ATTITUDE • SUPPORT

  48. PHYSICAL ASSESSMENT • PHYSICAL EXAMINATION • DISCOMFORTS OF PREGNANCY • DANGER SIGNS

  49. NUTRITIONAL ASSESSMENT • WEIGHT • HEIGHT • BMI • WEIGHT GAIN/LOSS • DIETARY HISTORY& INTAKE • CULTURAL FACTORS • PHYSICAL EXAMINATION

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