Transcript Assessment of the Pregnant Woman Student handout viewx

Assessment of the Pregnant
Woman
Anna H. Kelley MSN, ARNP, WHNP-BC
Clinical Assistant Professor
Assessment of the Pregnant Woman
• Assessment begins with a thorough Health history
including the following:
• Menstrual History
• Gynecological History
• Obstetrical History
• Current Pregnancy
• Medical History
• Family History
• Review of Systems
• Nutritional History
• Environmental Assessment
Menstrual History
• Age at Menarche (first menstrual period).
• Number of days in cycle.
• First day of your last menstrual period (LMP)
This is the first day of bleeding with your last
cycle.
• Was this a normal period for you in terms of
length, amount of flow, presence of cramping,
timing, and presence of premenstrual
symptoms.
Calculating EDD using Naegele’s rule
• The expected date of delivery (EDD) should be
280 days from LMP.
LMP
Add 7 days
Subtract 3 months
Plus one year
Naegele’s Rule Calculation
• Suppose a woman’s LMP was January 21,
2013. Calculate her estimated date of delivery
(EDD) using Naegele’s rule.
LMP 1-21-13
Plus 7 days 1-28-13
Minus 3 months 10-28-13
Plus one year 10-28-14
EDD 10-28-14
Naegele’s Rule Calculation
A woman’s LMP is June 20, 2014
Calculate her EDD using Nagele’s rule
Answer
• Her EDD is 3-27-15 .
• This calculation is based on the presumption
all women have a 28 day cycle and thus
ovulation would occur on day 14 of the cycle.
Using this calculation 90% of women will
deliver within 3 weeks of their EDD, 21%
within 3 days and approximately 4% will
deliver on their EDD.
• Use Naegele’s rule as an estimate.
Gynecological History
• History of reproductive surgery
• History of genital herpes
• Last PAP smear, history of abnormal PAP
findings and biopsy or follow-up intervention
• History of infertility or any uterine
abnormalities.
• History of sexually transmitted infections (STI)
and/or pelvic inflammatory disease (PID).
• History of breast disorders/breast surgery
Obstetrical History
Gravida/Parity
History of high risk conditions in pregnancy
Personal experience in previous pregnancies/deliveries.
Type of previous delivery: vaginal, vaginal assisted, CSection, or VBAC
Infertility/ART
Previous history of PTL/PTD
History of cervical insufficiency/incompetent cervix
Gestational age and weights of infants at birth
History of breastfeeding and personal satisfaction with
method of infant feeding
Gravida
Includes current and past pregnancies
• Gravida: woman who is pregnant
• Gravidity: pregnancy
• Primigravida: woman who is pregnant for the
first time.
• Multigravida : a woman who has had two or
more pregnancies
• Nulligravida: a woman who has never been
pregnant
Para/Parity
• Parity: number of pregnancies in which the
fetus(s) have reached viability.
• Viability : Ability to survive outside the uterine
cavity ( 22-24 weeks after LMP).
• Nullipara: woman who has not completed a
pregnancy with a fetus(s) reaching viability.
• Primipara: woman who has completed one
pregnancy with fetus(s) reaching viability.
• Multipara: woman who has completed two or
more pregnancies to viability.
Parity Systems
Can be written as two number system
G/P
or
Can be written as a four number system
G/FPAL
F=# of full term deliveries (38-42 weeks) GA
Multi-gestational pregnancies count as 1 delivery
P=# of pre-term deliveries(20-37 weeks) GA
A=# of abortions or miscarriages (SAB, EAB, TAB)
Refers to deliveries prior to 20 weeks gestation
L=# of living children
Calculating G/P
Ally Gator visits your prenatal clinic today for her
first prenatal appointment. She states her
LMP was approximately 6 weeks ago and
states she had a positive home pregnancy test
two weeks ago. She states her first pregnancy
she delivered twins at 34 weeks gestation and
both are living. She states prior to her twins
she had a miscarriage at 10 weeks of
pregnancy. Calculate G/P using the four
number parity system.
Answer
G 3 P 0-1-1-2
This is her third pregnancy. She has no full term
deliveries, one pre-term delivery (34 weeks)
of twins, one spontaneous abortion or
miscarriage, and has two living children ( the
twins).
Parity
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Note: Parity is not changed immediately
after a delivery but rather 28 days following
delivery so a primigravida who delivers a full
term infant today is still considered a G1/P0
when she is discharged from the hospital. She
is considered a G1/P1 or G1 P 1-0-0-1 after 28
days.
Current pregnancy
• Previous method of contraception-discontinuation date.
• Planned pregnancy? Feelings about pregnancy? Support of
FOB? Support group.
• History of symptoms since pregnant: vaginal bleeding, N/V,
abdominal pain, visual changes, edema, frequency/burning
on urination, vaginal discharge, or others.
• History of recent illness.
• Cats in the home.
• Fetal Movement?
• Plans for breastfeeding?
Medical History
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Allergies: Medications and other items
Personal or family history of cancer
History of asthma and intervention
History of German measles or chicken pox or
immunization date for each
History of back injury
Testing for HIV: date and result. High risk activities.
Tobacco, alcohol or recreational drug use
Medications: prescribed, OTC, or herbal
Exercise program
History of Vitamin D deficiency
Family History
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Hypertension
Diabetes
Mental illness including depression
Kidney disease
Fraternal twins
Congenital anomalies
Racial or Ethnic descent: Mediterranean,
African American, Jewish and Irish
Review of Systems
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Pre-pregnant weight
Visual issues/glasses/contacts
Dental issues/screenings/x-rays
Exposure to tuberculosis (TB)/date of last PPD
Cardiovascular disease
Anemia
History of thrombophlebitis/PE/DVT
History of hypertension or renal disease
History of Hepatitis, Thyroid disease, Seizures, Urinary tract
infections, or Diabetes.
• History of Depression/Mental illness
• Screening for Domestic Violence
Nutrition
• Vegetarian or special diets
• Food intolerance
Environmental Hazards
• Occupation
• Physical demands of work
• Exposure to strong odors, chemicals, and
radiation.
• Adequate food and housing
• Use of seatbelt when driving
General Survey
• Observe grooming, posture, mood and affect
View Maternal Child Nursing Care textbook Perry, Hockenberry,
Lowdermilk and Wilson page 225 for pictures of postural changes
during pregnancy.
• Assessment and recording of weight
• Observe for Lordosis in last trimester of pregnancy
• Clean catch urinalysis specimen for evaluation
• Ask if patient has concerns/questions that require answering
• If gestational age is greater than 16 weeks as about presence of
fetal movement (FM)
• Ask about presence of edema, headache, visual symptoms, burning
/frequency of urination, N/V, vaginal bleeding or discharge.
• Assessment and recording of Blood pressure
Skin
• Assessment of skin including presence of scars
indicative of previous reproductive surgery
including C-Section.
• Some skin changes during pregnancy including
acne and skin tags will generally resolve after
pregnancy.
• Presence of Chloasma ( the mask of pregnancy),
Linea nigra (hyper pigmented line extending from
sternum to symphysis pubis) and striae (stretch
marks).
Linea Nigra
Striae
“Stretch Marks”
Mouth and Neck
• Mucous membranes pink and moist
• Gum hypertrophy (pregnancy gingivitis) may
be present
• Bleeding gums ( estrogen stimulation)
Encourage dental hygiene and soft toothbrush
• Thyroid may feel full but should be smooth
unless disease is present
Pregnancy Gingivitis
Breasts
• Breasts enlarge and may be tender to palpation.
• Areola and nipples enlarge and become darker in
pigmentation. The nipples may become more erect.
• Blood vessels of the breasts enlarge and can be
visualized easily through seemingly transparent skin.
• Montgomery tubercles located around areola enlarge.
• Colostrum may be secreted as early as week 14 and
may be expressed from the nipples.
• Breast tissue feels nodular. Important for the pregnant
woman to continue her breast self examinations during
pregnancy.
Breast Changes in Pregnancy
Heart and Lungs
• Pregnancy often produces a functional, soft,
blowing systolic murmur as the result of
increased blood volume. The murmur requires no
treatment and will resolve after pregnancy.
• The lungs should be clear to auscultation
bilaterally without evidence of crackles or
wheezing. Shortness of breath may be present in
the third trimester and occurs from pressure on
the diaphragm from the enlarging uterus.
Peripheral Vasculature and Neurologic
• Legs may show bilateral pitting edema in the
third trimester especially if the woman is on
her feet for a prolonged period of time.
• Varicose veins are common in the third
trimester.
• Homan’s Sign is negative bilaterally
• Assess biceps and patellar deep tendon
reflexes (DTR). Normally these are 1+ to 2+
and equal bilaterally.
Abdomen
• As the woman in supine position lifts her head
you may see separation of the diastasis recti
abdominal muscles. These will return
together after pregnancy with the use of
abdominal exercise.
• The fundus (top of the uterus) will be palpable
abdominally after 12 weeks gestation.
• Obtain measurement of Fundal height after 20
weeks gestation.
Measuring Fundal Height
• With the woman in supine position using a
measuring tape with recording in centimeters,
measure from symphysis pubis to fundus.
After 20 weeks of gestation the number of
centimeters should be approximately equal to
the number of weeks gestation.
Leopold’s Maneuvers
• Leopold’s Maneuvers are an abdominal
assessment which give you information about
the placement of the fetus in utero. There are
four maneuvers involved in this assessment.
First Maneuver
• Used to determine the fetal part located in the
fundus. The examiner faces the patient’s head
and places their fingertips around the top of
the fundus. The fetal head will feel large,
round and firm in comparison to the buttocks
which will feel softer in comparison.
Second Maneuver
• Moving your hands to the sides of the uterus
note whether small parts ( arms, hands, legs
and feet) are palpable or whether you feel the
long firm surface of the back.
• Assessment of fetal heart tones ( the fetal
heartbeat) is best detected through the back
or shoulder.
Third Maneuver
• Have the woman bend her knees slightly and
palpate the lower abdomen just above the
symphysis pubis between the thumb and
fingers of one hand to determine the fetal
part present in the lower segment of the
uterus.
Fourth Maneuver
• Assists in determining engagement and to
differentiate a shoulder from the head. The
most difficult maneuver for a novice nurse to
perform. In this maneuver the examiner faces
the patients feet as they press on either side
of the lower abdomen.
Auscultation of Fetal Heart Tones
• Fetal heart tones are a positive sign of pregnancy.
They can be heard by Doppler around 10-12
weeks of gestation. FHT’s are best heard through
the back or shoulder of the fetus. Count for a full
minute if possible. Normal rate is between 110160 beats per minute. Accelerations of heart rate
are common with fetal movement and indicate
fetal well being.
• Differentiate the FHT’s from the slower maternal
pulse or heart rate.
Watch Fetal Assessment Video
http://www.youtube.com/watch?v=nIog3oizP8A
Pelvic Examination/Speculum
examination
• Assess genitalia: labial enlargement and
varicosities may be present. Presence of
vaginal discharge /unusual odor warrants
further investigation.
• Chadwick’s sign is the bluish/purplish
discoloration of the vaginal walls and cervix
due to increased vascularity and engorgement
of pregnancy.
Cervical Os
• Cervical os is round or dot like in a nulliparous
woman and looks like a transverse slit or
crooked line in a woman who has given birth
vaginally before.
• Refer to Maternal Child Nursing Care Textbook
Perry, Hockenberry, Lowdermilk and Wilson
page 214 Figure 10-2 for pictures showing
comparison of cervix in nullipara and
multipara woman.
Bimanual examination/Pelvimetry
• Hegar’s sign
• Goodell’s sign
• Assessment of pelvic shape: Gynecoid,
Android, Anthropoid or Platypelloid will give
an examiner and indication of how favorable
the bony structure of the pelvis is for a vaginal
delivery.
Questions
• Provide a time to answer patients questions.
• If you have questions related to the content of
this lecture please send me an email at
[email protected] and I will respond to the
entire class.