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NM650 Integrated Midwifery Practicum Clinical Objectives I. A. KNOWLEDGE: Primary Care of Women Systematically compiles & updates a complete & relevant database for the comprehensive assessment of each client’s health, incl. a thorough health hx & physical exam. 1. Incorporates basic principles of interpersonal relationships into interviewing and history-taking a. Introduces self b. Accepts and values client diversity c. Tells patient what to expect e. Sees to patient's comfort f. Cares for immediate concerns g. Shows interest in patient as an individual h. Avoids expression of inappropriate value judgments i. Uses eye-contact; demonstrates interest/listening j. Identifies/explores "clues" & significant comments k. Recognizes, evaluates, and responds appropriately to patient's nonverbal behavior 2. Uses appropriate interviewing techniques (1) Starts with present circumstance (2) Asks specific questions clearly and succinctly (3) Uses appropriate vocabulary (4) Explains new terms (5) Uses open-ended questions & responses (6) Pauses to allow for expression (7) Allows sufficient time to answer questions (8) Controls & keeps interview moving (9) Obtains complete data in a logical, orderly manner (10) Teaches appropriately (timing & information) (11) Terminates interview appropriately 3. Elicits a complete gynecological history, including: (1) Biographical (identifying) data (2) Personal/social (lifestyle, environmental) data (3) Chief complaint (4) Present obstetrical (health/illness) data (5) Past obstetrical/gynecological data (6) Past health (medical/surgical) data (7) Review of systems (8) Family health data 4. Performs a systematic, accurate, complete, and gentle physical examination on women in the childbearing years and screens for gross deviations and abnormalities. a. Initiates physical assessment by observing general appearance for: (1) Level of wellness/apparent state of health (2) State of awareness/affect (3) Signs of distress b. Examines the heart and respiratory system NM650: Integrated Midwifery Practicum Clinical Objectives c. d. e. Page 2 Examines the breasts and axilla (1) Prepares and informs client appropriately for breast examination (2) Inspects the breasts with the client in each of four positions for symmetry, elevation, and dimpling (retraction): -with arms at sides -with arms raised above head -with hands on waist and squeezing -with arms extending forward, chin up and bending forward at the waist as indicated (3) Inspects axilla and supraclavicular region for color, smoothness, and contour (4) Palpates axilla and supraclavicular region to rule out enlarged lymph nodes while client is sitting or after palpating breast (5) Palpates breast, gently but firmly, with part of fingers systematically while client is in the supine position with arm raised above her head (6) Describes any mass found in terms of location, size, shape, consistency, outline, mobility, and tenderness (7) Palpates nipple noting any discharge/deviation (8) Determines client's knowledge of/readiness to learn Self-Breast Examination (9) Teaches Self-Breast examination to client and obtains return demonstration from client as appropriate. Examines the abdomen (1) Assists client to relax abdominal wall (2) Monitors examination by watching client's face for sign of discomfort (3) Inspects abdomen for contour, symmetry, condition of skin and umbilicus, peristalsis, and pulsations (4) Auscultates abdomen for normal bowel sounds as indicated (5) Percusses abdomen for tympany versus dullness in four quadrants/nine sections as indicated (6) Percusses right upper quadrant to outline lower edge of liver as indicated (7) Lightly palpates abdomen noting and inguinal lymph nodes noting resistance/tenderness (8) Deeply palpates abdomen -Palpates lower edge of liver -Palpates left upper quadrant for spleen (9) Describes any masses found in terms of size, shape, location, consistency, mobility, and tenderness (10) Measures fundal height on a pregnant women (11) Systematically performs four steps of Leopold's maneuvers on pregnant abdomen Examines the back and the extremities (1) Notes client's movements and posture throughout the interview and examination (2) Inspects for symmetry of shoulders, hips, scapula (3) Observes spine noting the cervical, thoracic, and lumbar curves, and lateral curves if present Revised, 2011 according to: ACNM Standards for the Practice of Midwifery, 2003, and ACNM Code of Ethics, Revised 2004 , NM650: Integrated Midwifery Practicum Clinical Objectives Page 3 (4) Palpates spinous processes and paravertebral muscles to rule out tenderness (5) Palpates costovertebral angle area to rule out tenderness (6) Inspects extremities for: -edema -varicosities -equal size and shape of muscle mass -normal range of motion f. Examines the female reproductive system (1) Prepares room and assembles equipment (2) Prepares client by explaining/clarifying procedures and positioning comfortably (3) Inspects and palpates the external genitalia -Examines by gently "milking" the Skene's glands and urethra looking for exudate -Palpates for enlargement of Bartholin glands (4) Inspects the vagina and cervix using a speculum -Inserts speculum correctly and visualizes vagina and cervix -Obtains Pap Smear and/or G.C. culture, chlamydia culture or wet prep as indicated -Removes speculum correctly (5) Examines the pelvic area bimanually -Identifies the cervix and notes its size, shape, consistency, and mobility -Palpates the uterus and adnexa noting location, position, size, shape, consistency, and mobility -Locates and palpates the following landmarks of the bony pelvis: sacrospinous ligament, sacrum, coccyx subpubic arch, retropubic angle, sidewalls, ischial, ischial spines, tuberosities (6) Examines the rectum to evaluate sphincter tone, and explore for masses, lesions, nodes, external and internal hemorrhoids, fissures, fistulas, anorectal polyps or tumors g. Examines the extremities 5. Records examination findings completely, accurately, concisely, legibly, and in appropriate terminology 6. Accurately obtains or orders laboratory data as needed. B. Identifies problems/situations and formulates diagnoses based upon interpretation of the database. 1. Organizes data for preliminary diagnosis: a. clusters data appropriately b. identifies tentative diagnosis c. identifies missing information d. obtains additional data as necessary (includes history, physical, laboratory and other data) 2. Verifies diagnoses with appropriate faculty member. C. Identifies health care needs/problems in collaboration with the client: Provides information & support to enable clients to make informed decisions and to assume primary responsibility for their own health. (ACNM Code of Ethics, 2004, Statements 3 & 4) 1. Promotes mutual goal-setting between patient & self; between instructor & self Revised, 2011 according to: ACNM Standards for the Practice of Midwifery, 2003, and ACNM Code of Ethics, Revised 2004 , NM650: Integrated Midwifery Practicum Clinical Objectives 2. Page 4 a. Identifies own goals in situation b. Elicits goals of other(s) in situation c. Discusses points of agreement/conflict d. Arrives at mutually acceptable compromise of conflict Provides clear and accurate anticipatory guidance and counseling regarding: (ACNM Code of Ethics, 2004, Statement 3) a. D. general health promotion and wellness (primary, reproductive and breast health) b. primary health maintenance or problems/conditions within all systems c. contraception, family planning d. gynecological deviations from normal 1. breast findings 2. pap findings 3. pelvic findings e. laboratory findings for all body systems Develops a comprehensive plan of care with the client (ACNM Code of Ethics, 2004, Statement 3) 1. 2. E. F. G. H. II. Identifies possible treatment plans and consequences of each. Provides description of diagnosis, finalizing the plan of management of potential problems and rationale for plan. 3. Informs consumer of options, rationale, risks, sequelae, and limitations of therapeutic milieu including anticipated procedures (prior to institution of procedures) 4. Identifies need for appropriate additional lab tests. 5. Plans for subsequent assessment at appropriate intervals. 6. Utilizes appropriate faculty consultation for validation of management plan. 7. Selects most appropriate therapeutic plan based on valid rationale. 8. Verifies plan of care with appropriate faculty member. Assumes primary responsibility for the implementation of individualized plans. 1. Orders appropriate additional lab tests. 2. Orders appropriate treatment(s). 3. Performs appropriate procedures. 4. Arranges for subsequent assessments at appropriate intervals. 5. Obtains appropriate medical consultation or collaboration. 6. Records data legibly, concisely, and logically. 7. Facilitates entry into and utilization of health care system. 8. Verifies implementation with appropriate faculty member Obtaining consultation, planning, and implementing collaborative management; referral or transferring the care of the client as appropriate Initiates management of specific complications, emergencies and deviations from normal. 1. Verifies management with appropriate faculty member Evaluates, with the client, the effectiveness of care and modifying the plan of care as appropriate. 1. Predicts expected outcomes of management plan. 2. Identifies methods for follow-up evaluation. 3. Provides for follow-up evaluation when possible. 4. Identifies implications of treatment results for subsequent practice 5. Verifies evaluation with appropriate faculty member. KNOWLEDGE: Comprehensive Antepartal Care Revised, 2011 according to: ACNM Standards for the Practice of Midwifery, 2003, and ACNM Code of Ethics, Revised 2004 , NM650: Integrated Midwifery Practicum Clinical Objectives A. Page 5 Systematically compiles & updates a complete & relevant database for the comprehensive assessment of each client’s health, incl. a thorough health hx & physical exam. (ACNM Code of Ethics, 2004, Statement 1) 1. Reviews previous data when available 2. Identifies the purpose of the visit for the patient 3. Interviews patient appropriately, obtaining complete & relevant historical information a. Family medical/surgical b. Personal medical-surgical c. Ob-gyn (include menstrual, sexual, contraceptive) d. Drug use (over-the counter, prescribed, and recreational) e. Psychosocial f. Current obstetric course g. Obtains complete & relevant information since last visit on: (1) common complaints/discomforts of pregnancy (2) potential complications/danger signs (3) diagnosis of and/or progress of pregnancy (4) emotional well-being (5) impact of pregnancy on family or significant others (6) nutrition 4. Gives patient appropriate preparatory explanation of exam procedures 5. Performs review of systems and appropriate physical examination of patient systematically, completely, accurately. a. Checks: blood pressure weight status urine (glucose, protein, ketones, leukocytes) reflexes (as indicated) CVAT (as indicated) edema, (pretibial, facial, pedal, digital) b. head to toe PE when appropriate with special attention to abdominal findings: fundal height fetal heart tones (doptone) fetal heart tones (fetoscope) fetal movement fetal presentation, position, lie estimate fetal weight pain, tone, tenderness, contractions c. pelvic exam as indicated -Locates and palpates the following landmarks of the bony pelvis: sacrospinous ligament, sacrum, coccyx subpubic arch, retropubic angle, sidewalls, ischial, ischial spines, tuberosities pelvic musculature and soft tissue cervical status uterine sizing d. using instruments, performs procedure correctly speculum Pap smear cultures Revised, 2011 according to: ACNM Standards for the Practice of Midwifery, 2003, and ACNM Code of Ethics, Revised 2004 , NM650: Integrated Midwifery Practicum Clinical Objectives Page 6 wet mount microscope sterile speculum 6. Obtains all routine laboratory data a. Reviews chart for previous laboratory data b. Orders or obtains appropriate laboratory tests at correct times, utilizing appropriate technique c. Obtains additional data as necessary (1) history (2) physical (3) lab (4) records (5) friends/relatives of patients (6) other professionals involved with care 7. Screens patients for the following: a. Anemia b. UTI c. PIH d. Diabetes e. Drug/alcohol problems f. Infectious diseases/STDs g. Nausea/Vomiting h. Multiple gestation i. Vaginal bleeding j. Abnormal presentation k. Size/dates discrepancy l. Psychosocial/sexual problems m. Intimate partner violence n. Nutritional deficiencies o. Genetic counseling p. Indications for antenatal testing q. Preterm labor B. Identifies problems/situations and formulates diagnoses based upon interpretation of the database. 1. Organizes data for preliminary diagnosis: a. clusters data appropriately b. identifies tentative diagnosis c. identifies missing information d. obtains additional data as necessary (includes history, physical, laboratory and other data) 2. Verifies diagnoses with appropriate faculty member. C. Identifies health care needs/problems in collaboration with the client: Provides information & support to enable clients to make informed decisions and to assume primary responsibility for their own health. (ACNM Code of Ethics, 2004, Statement 3 & 4) 1. Promotes mutual goal-setting between patient & self; between instructor & self a. Identifies own goals in situation b. Elicits goals of other(s) in situation c. Discusses points of agreement/conflict d. Arrives at mutually acceptable compromise of conflict Revised, 2011 according to: ACNM Standards for the Practice of Midwifery, 2003, and ACNM Code of Ethics, Revised 2004 , NM650: Integrated Midwifery Practicum Clinical Objectives Page 7 2. D. E. F. G. Provides clear and accurate anticipatory guidance and counseling regarding: a. warning signs – indications to call provider b. fetal development c. nutrition during pregnancy d. minor discomforts of pregnancy and their management e. labor and delivery f. complications of pregnancy and their prevention 1. Anemia 2. UTI 3. PIH 4. Diabetes 5. Drug/alcohol problems 6. Infectious diseases/STDs 7. Nausea/Vomiting 8. Multiple gestation 9. Vaginal bleeding 10. Abnormal presentation 11. Size/dates discrepancy 12. Psychosocial/sexual problems 13. Intimate partner violence 14. Nutritional deficiencies 15. Genetic counseling 16. Indications for antenatal testing 17. Preterm labor Develops a comprehensive plan of care with the client 1. Identifies possible treatment plans and consequences of each. 2. Provides description of diagnosis, finalizing the plan of management of potential problems and rationale for plan. 3. Informs consumer of options, rationale, risks, sequelae, and limitations of therapeutic milieu including anticipated procedures (prior to institution of procedures) 4. Identifies need for appropriate additional lab tests. 5. Plans for subsequent assessment at appropriate intervals. 6. Utilizes appropriate faculty consultation for validation of management plan. 7. Selects most appropriate therapeutic plan based on valid rationale. 8. Verifies plan of care with appropriate faculty member. Assumes primary responsibility for the implementation of individualized plans. 1. Orders appropriate additional lab tests. 2. Orders appropriate treatment(s). 3. Performs appropriate procedures. 4. Arranges for subsequent assessments at appropriate intervals. 5. Obtains appropriate medical consultation or collaboration. 6. Records data legibly, concisely, and logically. 7. Facilitates entry into and utilization of health care system. 8. Verifies implementation with appropriate faculty member Obtaining consultation, planning, and implementing collaborative management; referral or transferring the care of the client as appropriate Initiates management of specific complications, emergencies and deviations from normal. 1. Verifies management with appropriate faculty member Revised, 2011 according to: ACNM Standards for the Practice of Midwifery, 2003, and ACNM Code of Ethics, Revised 2004 , NM650: Integrated Midwifery Practicum Clinical Objectives Page 8 H. Evaluates, with the client, the effectiveness of care and modifying the plan of care as appropriate. 1. Predicts expected outcomes of management plan. 2. Identifies methods for follow-up evaluation. 3. Provides for follow-up evaluation when possible. 4. Identifies implications of treatment results for subsequent practice 5. Verifies evaluation with appropriate faculty member. III. KNOWLEDGE: INTRAPARTUM A. Systematically compiles & updates a complete & relevant database for the comprehensive assessment of each client’s health, incl. a thorough health hx & physical exam. 1. Reviews previous data when available 2. Identifies the purpose of the visit for the consumer 3. Identifies the purpose of the visit for the health care provider 4. Interviews consumer appropriately, obtaining complete and relevant historical information a. Family medical-surgical b. Personal medical-surgical c. Obstetrical/gynecological (including menstrual, sexual, contraceptive) d. Medications e. Psychosocial/Environmental 5. Performs review of systems and systematic review of systems in appropriate physical examination of the client. a. Performs abdominal examinations: 1. Fundal height (+ /- 1 cm) 2. Leopold's maneuvers for lie, attitude, presentation, position 3. Contraction intensity, frequency, duration, quality, stage of labor 4. Fetal weight (within 1/2 lb) 5. Uterine tonus and shape 6. Abdominal muscles 7. Presence or absence of hydramnios b. Performs vaginal examinations (including sterile speculum as needed) 1. Cervical effacement (+/- 20%) and dilation (+/- 1 cm) and position 2. Condition of membranes 3. Documentation of ROM (color, odor, amount, fern, nitrazine) 4. Fetal position, presentation, and station c. Performs clinical pelvimetry d. Completes focused physical exam incl. above 1. Edema 2. Varicosities/Homan's sign 3. DTR’s and clonus 4. CVA tenderness 5. Vital signs 6. Heart, lungs, breast exam e. Auscultates fetal heart tones with attention to baseline, variability, acceleration, deceleration, periodic changes. f. Monitors maternal/fetal vital signs 1. Maternal pulse, blood pressure, temperature 2. Shows knowledge of satisfactory techniques for intermittent auscultation of FHT Revised, 2011 according to: ACNM Standards for the Practice of Midwifery, 2003, and ACNM Code of Ethics, Revised 2004 , NM650: Integrated Midwifery Practicum Clinical Objectives Page 9 3. g. h. i. j. Shows knowledge of continuous fetal monitoring application and interpretation Times and performs procedures appropriately 1. FHT monitoring a. Fetoscope b. Doptone c. External fetal and uterine electronic monitoring d. Internal fetal scalp electrode 2. uterine pressure catheter 3. AROM 4. IV therapy 5. Medication 6. Local perineal anesthesia Performs episiotomy if indicated: 1. Assesses the need for episiotomy appropriately 2. Selects appropriate time for cutting episiotomy 3. Administers anesthesia correctly and with minimal discomfort to client 4. Cuts episiotomy firmly and smoothly with minimum number of cuts 5. Correctly obtains hemostasis via suturing for episiotomy or laceration Supports birth of infant skillfully: 1. Observes the following mechanisms of 2nd stage: descent, internal rotation 2. Keeps head flexed 3. Assesses perineum 4. Maintains slow controlled extension of head (uses modified Ritgen maneuver if necessary) 5. Suctions with bulb and/or wipes face as indicated 6. Feels for nuchal cord and slips cord over head, or delivers infant through cord, or clamps and cuts cord and unwinds cord 7. Observes the following mechanism of 2nd stage: restitution and external rotation 8. Places hands securely on head 9. Guides birth of shoulders, while observing perineum, by providing steady pressure downward for anterior shoulder, upward for posterior shoulder 10. Supports birth of body by sliding posterior hand down neck and over shoulder with fingers on chest, thumb on back, head resting on arm 11. Further secures newborn by sliding anterior (top) hand down back, grasping legs with index finger between ankles 12. Moves in close to perineum to avoid strain and pulling on cord 13. Tucks infant's body under appropriate arm, supporting head in palm of hand 14. Keeps head lowered and turned to one side 15. Clamps and cuts cord appropriately, takes specimens 16. Modifies the above as appropriate depending upon client’s position Initiates newborn resuscitation as needed including: 1. Establishes airway, suctions and dries infant 2. Performs bag and mask ventilation Revised, 2011 according to: ACNM Standards for the Practice of Midwifery, 2003, and ACNM Code of Ethics, Revised 2004 , NM650: Integrated Midwifery Practicum Clinical Objectives Page 10 3. Initiates cardiac compressions 4. Performs tracheal intubation 5. Calls for pediatric help 6. Evaluates for hypothermia, hypoglycemia while awaiting help. k. Delivers and examines placenta and membranes: 1. Obtains cord blood 2. Observes for signs of placental separation 3. Checks placental separation by modified Brandt-Andrews, following cord up vagina to cervix if necessary 4. If not separated, waits appropriately 5. Inspects perineum while awaiting placental separation 6. Delivers placenta by: a. Guarding uterus b. Controlled cord traction c. Encouraging maternal efforts d. Following curve of Carus 7. While supporting placenta guards membranes by twisting or applying ring forceps to membranes 8. Examines placenta, membranes and cord 6. Obtains all routine laboratory data a. Venipuncture/fingerstick b. Urine specimen (clean catch/catheterization) c. Cervical culture by sterile speculum exam d. Others as needed e. Labels specimens/requisitions correctly 7. Organizes data for preliminary diagnosis and completes data base a. Clusters data appropriately b. Identifies tentative diagnoses c. Identifies missing information d. Obtains additional data as necessary (includes history, physical, laboratory and other data) 8. Validates assumptions. B. Identifies problems/situations and formulates diagnoses based upon interpretation of the database. 1. Malpresentation 2. Cord Prolapse 3. Shoulder Dystocia 4. Postpartum Hemorrhage 5. Uterine Rupture 6. Uterine Inversion 7. Hematomas 8. Fetal Distress 9. Prolonged Labor/Dysfunctional Labor 10. Maternal anxiety 11. Cultural attitudes regarding care 12. Prematurity/Postmaturity 13. Prolonged ROM C. Identifies health care needs/problems in collaboration with the client: Provides information & support to enable clients to make informed decisions and to assume primary responsibility for their own health. Revised, 2011 according to: ACNM Standards for the Practice of Midwifery, 2003, and ACNM Code of Ethics, Revised 2004 , NM650: Integrated Midwifery Practicum Clinical Objectives Page 11 D. Develops a comprehensive plan of care with the client 1. Identifies possible treatment plans and consequences of each. 2. Provides description of diagnosis, finalizing the plan of management of potential problems and rationale for plan. 3. Informs consumer of options, rationale, risks, sequelae, and limitations of therapeutic milieu including anticipated procedures (prior to institution of procedures) 4. Identifies need for appropriate additional lab tests. 5. Plans for subsequent assessment at appropriate intervals. 6. Utilizes appropriate faculty consultation for validation of management plan. 7. Selects most appropriate therapeutic plan based on valid rationale. E. Assumes primary responsibility for the implementation of individualized plans. 1. Orders appropriate additional lab tests. 2. Orders appropriate treatment(s). 3. Performs appropriate procedures. 4. Arranges for subsequent assessments at appropriate intervals. 5. Obtains appropriate medical consultation or collaboration. 6. Records data legibly, concisely, and logically. 7. Facilitates entry into and utilization of health care system. F. Obtaining consultation, planning, and implementing collaborative management; referral or transferring the care of the client as appropriate H. Initiates management of specific complications, emergencies and deviations from normal. 1. Malpresentation 2. Cord Prolapse 3. Shoulder Dystocia 4. Postpartum Hemorrhage 5. Uterine Rupture 6. Uterine Inversion 7. Hematomas 8. Fetal Distress 9. Prolonged Labor/Dysfunctional Labor 10. Maternal anxiety 11. Cultural attitudes regarding care 12. Prematurity/Postmaturity 13. Prolonged ROM H. Evaluates, with the client, the effectiveness of care and modifying the plan of care as appropriate. 1. Predicts expected outcomes of management plan. 2. Identifies methods for follow-up evaluation. 3. Provides for follow-up evaluation when possible. 4. Identifies implications of treatment results for subsequent practice IV. KNOWLEDGE: MATERNAL/NEWBORN CARE DURING THE PUERPERIUM AND NEONATAL PERIODS. A. Systematically compiles & updates a complete & relevant database for the comprehensive assessment of each client’s health, incl. a thorough health hx & physical exam. 1. Reviews the women's chart for pertinent data from prenatal, labor/delivery, and postpartum courses. Includes significant information regarding the cultural, socioeconomic, psychosocial and physical factors that influence family relationships. Revised, 2011 according to: ACNM Standards for the Practice of Midwifery, 2003, and ACNM Code of Ethics, Revised 2004 , NM650: Integrated Midwifery Practicum Clinical Objectives 2. 3. 4. 5. 6. 7. 8. Page 12 Identifies preliminary goals of the visit for the consumer and for the nursemidwife. Obtains interim maternal history to elicit relevant additional data 1. common physical discomforts a. elimination b. diet and nutrition c. breast-feeding / bottle feeding d. analysis of significant abnormal signs or symptoms e. medications, rationale for use, implications f. sleep/rest 2. Risk Factors for inappropriate emotional response to postpartum period Conducts a thorough and relevant physical examination, including assessment of the breasts, abdomen, perineum, extremities, and back. Expands physical examination appropriately when a deviation from normal occurs. a. Breast examination - demonstrate/teach self breast exam b. Abdominal examination including: 1. Musculature and tone 2. Diastasis recti 3. Fundus - location and levels, involution, tenderness 4. Urinary bladder c. Perineal examination including: 1. Vulva - hematoma, edema, varicosities, lacerations 2. Perineum/episiotomy - discomfort, healing, hematomas 3. Rectum - hemorrhoids d. Lochia evaluation - color, amount, odor e. Lower extremities - edema, pain, varicosities Orders and/or obtains appropriate laboratory tests and referrals necessary for evaluation of a deviation from normal. Reviews the infant's chart when available for pertinent data from a.. family medical history 1. social and cultural history 2. mother's antepartal / intrapartal history 3. newborn's status since birth - nutritional/developmental 4. laboratory data Screens newborn for indications for the following: a. hypothermia, hyperthermia b. abnormal heart rate or rhythm c. failure to make cardiovascular adjustments d. failure to make pulmonary adjustments e. size/dates discrepancy, SGA / LGA f. neurological deficits g. physical anomalies h. drug dependency i. infection j. jaundice k. blood incompatibilities l. feeding and elimination m. breastfeeding problems Revised, 2011 according to: ACNM Standards for the Practice of Midwifery, 2003, and ACNM Code of Ethics, Revised 2004 , NM650: Integrated Midwifery Practicum Clinical Objectives Page 13 B. Identifies problems/situations and formulates diagnoses based upon interpretation of the database. 1. Organizes data for preliminary diagnosis: a. clusters data appropriately b. identifies tentative diagnosis c. identifies missing information d. obtains additional data as necessary (includes history, physical, laboratory and other data) 2. Verifies diagnoses with appropriate faculty member 3. For conditions, see B.1. and B.2. C. Identifies health care needs/problems in collaboration with the client: Provides information & support to enable clients to make informed decisions and to assume primary responsibility for their own health. 1. Provides clear and accurate anticipatory guidance and counseling regarding: a. processing of labor and delivery experience b. potential psychological / emotional adjustment c. nutrition d. activity/sleep e. breast care for nursing / non-nursing mothers f. relief of breast engorgement/sore nipples g. relief of afterbirth pains h. diaphoresis/diuresis i. relief of episiotomy/laceration pain j. lochia k. perineal hygiene l. relief of hemorrhoid pain m. resumption of sexual activity n. contraception o. warning signs p. follow-up visits/tests q. infant care r. lab tests / referrals D. Develops a comprehensive plan of care with the client 1. Identifies possible treatment plans (incl. alternatives) and consequences of each. 2. Provides description of diagnosis, finalizing the plan of management of potential problems and rationale for plan. 3. Informs consumer of options, rationale, risks, sequelae, and limitations of therapeutic milieu including anticipated procedures (prior to institution of procedures) 4. Identifies need for appropriate additional lab tests. 5. Plans for subsequent assessment at appropriate intervals. 6. Utilizes appropriate faculty consultation for validation of management plan. 7. Selects most appropriate therapeutic plan based on valid rationale. 8. Verifies plan of care with appropriate faculty member E. Assumes primary responsibility for the implementation of individualized plans. 1. Orders appropriate additional lab tests. 2. Orders appropriate treatment(s). 3. Performs appropriate procedures. 4. Arranges for subsequent assessments at appropriate intervals. 5. Obtains appropriate medical consultation or collaboration. Revised, 2011 according to: ACNM Standards for the Practice of Midwifery, 2003, and ACNM Code of Ethics, Revised 2004 , NM650: Integrated Midwifery Practicum Clinical Objectives Page 14 6. Records data legibly, concisely, and logically. 7. Facilitates entry into and utilization of health care system. 8. Verifies implementation with appropriate faculty member F. Obtains consultation, plans, and implements collaborative management; referral or transferring the care of the client as appropriate 1. For conditions listed in B.1 and B.2 2. Makes observations relevant to psychosocial/emotional adjustment of client and family a. investigates client's / family's processing of the labor and birth experience b. observes family interactions revealing clues to bonding, family relationships, and adaptation to the infant c. identifies client's/family's grief process when relevant G. Initiates management of specific complications, emergencies and deviations from normal. 1. Verifies management with appropriate faculty member 2. For conditions listed in B.1 and B.2. H. Evaluates, with the client, the effectiveness of care and modifying the plan of care as appropriate. 1. Predicts expected outcomes of management plan. 2. Identifies methods for follow-up evaluation. 3. Provides for follow-up evaluation when possible. 4. Identifies implications of treatment results for subsequent practice. 5. Verifies evaluation with appropriate faculty member. V. SKILLS A. Performs all skills in a manner which: 1. Demonstrates correct and efficient utilization of hands, instruments, and equipment. 2. Results in obtaining accurate data or in the safe completion of an appropriate procedure/maneuver. 3. Causes the least possible physical and/or psychological discomfort to the consumer. 4. Demonstrates consistency. VI. VALUES A. Incorporates appropriate values in the assessment process. 1. Values diversity. 2. Respects and integrates client’s values. B. Demonstrates actions, interactions and attitudes consistent with ACNM Standards for the Practice of Midwifery (2003) and ACNM Code of Ethics (2004.) 1. Demonstrates actions, interactions and attitudes that positively facilitate intra and interdisciplinary collegiality. C. Demonstrates actions, interactions and attitudes that facilitate achievement of the following Hallmarks of Midwifery (2002): Recognition of pregnancy, birth, and menopause as a normal physiologic and developmental process Advocacy of non-intervention in the absence of complications Incorporation of scientific evidence into clinical practice Promotion of family-centered care Empowerment of women as partners in health care Facilitation of healthy family and interpersonal relationships Promotion of continuity of care Revised, 2011 according to: ACNM Standards for the Practice of Midwifery, 2003, and ACNM Code of Ethics, Revised 2004 , NM650: Integrated Midwifery Practicum Clinical Objectives Page 15 V. A. B. Health promotion, disease prevention, and health education Promotion of a public health care perspective Care to vulnerable populations Advocacy for informed choice, shared decision-making, and the right to selfdetermination Cultural competence Familiarity with common complementary and alternative therapies Skillful communication, guidance, and counseling Therapeutic value of human presence Collaboration with other members of the health care team. MEANINGS Individual Qualities 1. Takes responsibility for own learning. 2. Achieves appropriate theory grasp. 3. Accepts responsibility for decision-making and consequences. 4. Demonstrates integrity and reliability. 5. Develops an environment of mutual respect in any professional interaction. 6. Demonstrates ability to cope with stressful or emotional situations in a constructive manner. 7. Knows own limitations; protects the safety of the client. Communication 1. Exchanges information in manner which consumer understands and provides an opportunity for asking questions (interaction). 2. Communicates appropriately with health care team members, faculty and peers. 3. Promotes family centered care and provides opportunity for consumer to receive support from significant other. 4. Maintains and respects privacy. 5. C. Promotes consumer's rights to make and be responsible for decision concerning personal health care. 6. Demonstrates sensitivity to the biases/constraints of the consumer. Approach to Health Care System 1. Identifies bioethical considerations related to reproductive health. 2. Uses appropriate community resources. 3. Advocates principles of health promotion and disease prevention. 4. Promotes pregnancy as a normal physiologic process. 5. Demonstrates awareness of cost/benefits ratio in health care. Revised, 2011 according to: ACNM Standards for the Practice of Midwifery, 2003, and ACNM Code of Ethics, Revised 2004 ,