Download Admission Assessment of the Pregnant Woman

Admission Assessment of the
Pregnant Woman
Evelyn M. Hickson, RN, MSN, CNS, WCC
Objectives
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Identify potential complications of pregnancy
based on prenatal history, physical
assessment and lab values.
Discuss the role of the perinatal nurse in
screening, identifying, documenting and
referring patients with history of domestic
violence or substance use during pregnancy.
Discuss maternal infections, modes of
treatment, and potential impact on the infant.
Review of Prenatal Records
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Review office reports, including
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Obstetrical history
Personal medical history
Family history
Social history
Note any areas of concern identified by
the care provider
Prenatal Labs
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Blood type and antibody screen
Rubella immunity
GBS culture
HSV
HIV
Hepatitis B
VDRL/RPR
Quad screen
Glucose tolerance testing
OB History: Current Pregnancy
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Maternal age
EDC
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Dating criteria
How early did she start prenatal care?
Gestation
Current complications
GTPAL
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Gravidity
Term births
Preterm (<37 wk) births
Abortions (elective, therapeutic or spontaneous)
Living children
OB History: Multiparous Patients
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Length of previous labors, infant birth
weight, gestational age at delivery
History of preterm labor or delivery
Previous operative delivery
Previous stillbirth
History of postpartum hemorrhage or
postpartum depression
Social History
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Marital status or available family support
CPS or other alerts
Social/economic/educational concerns
Physical/mental challenges
Referral to social services
Language barriers
Religious or cultural practices
Prioritizing the Patient Interview
Sometimes the urgency of the situation
dictates the order in which one proceeds
with a patient interview, such as:
 Imminent delivery
 Unstable maternal condition
(Unconscious, bleeding, seizing, etc)
 Category 3 fetal tracing
Patient Interview
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Note the date and time of patient arrival
Is your baby moving?
Are you contracting? If so, when did they start
and how often are they occurring?
Are you experiencing vaginal bleeding,
discharge, or leaking of fluid?
Are you in pain? Orient the patient to the pain
scale and discuss her plans for pain
management.
Send them to bathroom for UA.
Patient Interview (cont.)
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Current medications
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Dose, route, last taken
Allergies and reactions
When the patient last ate or drank
(including what was eaten or drunk)
Recent SVE
Complications with current or previous
pregnancy
Is the patient experiencing…
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Nausea or vomiting
Frequency or burning with urination
Epigastric pain
Headaches
Visual disturbances
Physical Assessment
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Leopold’s Maneuvers
EFM
 Orient patient to
monitors and basic
strip interpretation
Physical Assessment
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Vital signs (full set)
Urine dip
Physical exam including:
Edema
DTRs and Clonus
Breath sounds if patient presents with
respiratory symptoms
SVE – unless contraindicated
Labor Assessment
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Time contractions started
Frequency, duration, and regularity of
contractions
Palpation of maternal abdomen during and
between contractions
Fetal movement
Pain assessment, including location and
type of pain
Herbs/Foods That Increase
Uterine Activity
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Bitter Melon
Castor bean or castor oil
Chamomile tea
Cinnamon (spice tea)
Garlic
Ginger
Goldenseal
Pomegranate
Red raspberry leaf tea
Suspected Rupture of Membranes
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Intercourse in last 12-24 hours
Time possible SROM occurred
Color, amount, and smell of fluid
Testing of vaginal discharge for
presence of amniotic fluid
Substance Use and Abuse
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Warning signs of drug abuse:
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Intrapartum signs of substance abuse
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Noncompliance with prenatal care – late entry or no prenatal
care
Poor nutrition –due to adolescence, obesity, low socioeconomic
status
Current or previous history of encounters with law enforcement
Marital & family disputes
Unexplained IUGR
3rd trimester stillbirth
Unexpected preterm birth
Placental abruption in a woman without hypertensive disorders.
Informed consent for testing
Social service consult, CPS, drug treatment
Domestic Violence
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Majority of abused women continue to be
victimized during pregnancy and may escalate.
Most estimate rates between 4 –8%.
Child abuse occurs in 33 – 77% of families with
adult abuse.
No single profile of an abused woman: all
racial, economic, educational, religious, ethnic
and social backgrounds.
Pregnancy and Domestic Violence
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Signs of domestic violence in the pregnant
patient include:
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unwanted pregnancy
late entry into prenatal care
missed appointments
substance abuse or use
poor weight gain and nutrition
multiple, repeated somatic complaints.
Domestic Violence Screening
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Should be conducted in private, with
only the patient present
“Because violence against women is so
common, I ask all of my patients do you
have any reason to feel unsafe at
home?”
Document patient statements
accurately and quote them directly
Promptly Notify Care Provider if:
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Vaginal bleeding
Acute abdominal pain
Temperature of 100.4 F or higher
Preterm labor
Preterm rupture of membranes
Hypertension
Non-reassuring fetal heart rate pattern
SBAR Communication
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Best method to speak to providers
Gives you a standard list of things you
need to be prepared to discuss with
them
Be concise and factual
Do not use “touchy-feely” language
SBAR Communication
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Situation
What is going on with the patient?
Background
What is the clinical context?
Assessment
What do I think the problem is?
Recommendation
What would I do to correct it?
SBAR Guideline
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Prior to calling the provider:
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Have I assessed the patient myself?
Has the situation been discussed with a resource
nurse or preceptor?
Have the following available when speaking:
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Patient chart
List of current medications, allergies, whether IV was placed
and labs drawn
Most recent vital signs
Reporting lab results: provide the date and time test was
done and results of previous labs for comparison
SBAR: Situation
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What is the situation you are calling
about?
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Identify self, unit, patient, room number
State who the patient’s doctor has been for
the pregnancy
Briefly state the problem, what is it, when it
happened or started, and how severe.
SBAR: Background
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Pertinent background information related
to the situation could include:
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Gestation, GTPAL, age, previously
identified risk factors
List of current medications, allergies, labs
Most recent vital signs
Clinical information
SBAR: Assessment and
Recommendation
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What is your assessment of the situation?
What is your recommendation or
expectation?
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Admission for labor
Patient needs to be seen now
Patient needs antibiotics for UTI, etc.
Document the care provider notification,
orders received, changes in patient
Guidelines for Communication with
Physicians Using SBAR
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Use the following according to provider preference.
 Direct page
 Call service
 During weekdays, the office directly
 On weekends and after hours during the week, home
phone
 Cell phone.
Wait no longer than 5 minutes between attempts.
For emergent situations, use the appropriate chain of
command as needed to ensure safe patient care.
References
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Guidelines for Perinatal Care, (6th ed.)/AAP and
ACOG, 2005
Lowdermilk, D. and Perry, S. (2007). Maternity
and Women’s Health Care (9th ed.). St. Louis,
MI: Mosby Elsevier.
Mattson, S. and Smith, J. (2004). Core
Curriculum for Maternal-Newborn Nursing (3rd
ed.). St. Louis, MI: Mosby Elsevier.
Simpson, K. and Creehan, P. (2010). Perinatal
Nursing (3rd ed.). Philadelphia, PA: Lippincott.