Tiêu đề WK3 & 5 - Physical Assessment of Normal Pregnant Client.pdf ✅

J.A.K.E 1 of 4 Discussed by: Prof. Carmen Pacis Prof. Donato Mirador Bachelor of Science in Nursing 2YA NCMA217 RLE: ASSESSMENT OF NORMAL PREGNANT CLIENT PHYSICAL ASSESSMENT OF NORMAL PREGNANT CLIENT Frequency of Prenatal Visit Weeks of Gestation Frequency of Visit Week 4 – 28 1 per month Week 28 – 36 1 every two weeks Week 36 – 40 1 every week - Pregnant women are also having complicated situation - Tinatanong sila kung kalian babalik for check up - Pre-natal visit once for month - Kapag 7 months, twice every 2 weeks - Pre-natal check up every week, kapag kabuwanan na According to DOH minimum of 4 Prenatal Check-up: • 1st trimester = 1st visit • 2nd trimester = 2nd visit • 3rd trimester = 3rd & 4th visit According to OB Book • 1st – 6th month = once a month • 7th – 8th mo. = twice a month • 9th mo. = weekly Why do we need to perform physical assessment? - So that we could assess the General Appearance • Assessing nutritional status • Weight • Height • Uterine assessment - For each assessment we could determine the symptoms General Approach - Make sure to always provide comfort and sense of privacy - Have the needed equipment readily at hand - Provide gown and drapes for abdominal examination - Instruct the client to empty her bladder prior to examination (kapag puno ang bladder hindi mapapalpate ng maayos) Positon - Semi sitting position with the knees bent - Supine position with pillow under the legs (pero most of the time semi sitting yung ginagawa kase hindi masyado comfortable ang mother pag supine) Equipment • The examiners hand is the “primary equipment” for assessment • Tape measure • Stethoscope/fetal doppler • Clean gloves (if needed) General Examination Appearance – inspection of the overall health. • Nutritional status • Emotional state • Neuromuscular coordination • Weight, height (para ma assess kung gaano lang dapat kadami ang bigat ng babae habang nag bubuntis. Kase if ever na mag overweight ang mother risk for her and the baby) BMI – Body Mass Index Formula Metric Units BMI = Weight (kg) / Height (m)2 English Units BMI = 703 x Weight (lbs) / Height (in)2 - 703 is the conversion factor for lbs/in2 to kg/m2 BMI Pre-pregnancy Interpretation Recommended weight gain BMI less than 18.0 Under weight 28 to 40 lbs. (13 to 18 kg) 18.0 to 24.9 Normal weight 25 to 35lbs (11 to 16 kg) 25.0 to 29.9 Overweight 15 to 25 lbs (9 to 11 kg) 30 or more Obese 11 to 20 lbs (5 to 9 kg) The healthy weight ranges - 1 to 1.5 kg –in the first three months - 1.5 to 2 kg – each month until they give birth. Example: - If weight is 90 kg - Height is 1.77 m - What is BMI? Solution → First you need to multiply 1.77 to itself; 1.77 x 1.77 = 3.1329. → So, 3.1329 is the height in meters, now you can solve the BMI → 90 / 3.1329 = 28.7 (BMI) Calculating the mothers BMI is essential • Low BMI (less than 18) can result in: - Fetal growth restriction • High BMI (more than 35) can result in: - Gestation diabeste - Pre-eclampsia - Emergency C-section - Anesthetic difficulty Obstetric History - Involves asking questions relevant to a patient current and previous pregnancy. Some of the questions are highly personal and therefore good communication skills and a respectful manner are absolutely essentials Gravida - total number of pregnancies, this includes the number of times the woman is or has been pregnant regardless of the outcome. A current pregnancy is included in this count. Para - total no. of deliveries > 20 weeks AOG - total number of viable pregnancies, this indicates number of pregnancies reaching viable gestational age (including live births and stillbirth. The number of fetuses does not determine the parity. - Viability – the ability of the fetus to live outside the uterus at the earliest possible gestational age 20 – 24 weeks or 5 – 6 month Term – total no of infants born at term / 37 weeks / more
NCMA217 RLE: PHYSICAL ASSESSMENT OF NORMAL PREGNANT CLIENT (MAM PACIS & SIR MIRADOR) J.A.K.E 2 of 4 Preterm – total no. of infants born before 37 weeks Abortion – total number of spontaneous or induced abortions below 20 weeks gestation Living – total number of children currently living Multiple – total number of multiple pregnancies General Rule: • Multiple gestation (twins/triplets etc.) is counted as one pregnancy and counted as one parity • Still birth/intrauterine fetal demise (IUFD) – is counted as one viable pregnancy – • if it falls between 37 – 42 weeks it is under a term pregnancy • if it falls less than 37 weeks but more than 20 weeks it is counted in preterm pregnancy • if the product of conception was delivered before the age of viability (20-24weeks) it is considered Abortion Head and Neck • Hair: note for texture, moisture, and distribution, dryness, oiliness • Eyes: anemia of pregnancy may cause pallor • Nose: nasal congestion is common among pregnant women and nose bleeds • Mouth: inspect for gums and teeth, gingival enlargement with bleeding is common • Thyroid: symmetrical enlargement may be expected • Skin pigmentation changes: Chloasma/ melasma gravidarum – irregular brownish patches of varying size appear on the face and neck, “mask of pregnancy” • Spider telangiectasia – a vascular stellate marks resulting from high level of estrogen. Typically develop in face, neck, upper chest and arm. Thorax and Lungs • Inspect thorax for the pattern of breathing Heart • Palpate for the apical impulse. Sometimes it may be slightly higher than normal due to higher diaphragm • Auscultate the heart; soft blowing are common, reflecting the increased blood flow in normal vessels Breast • inspect breast and nipple for symmetry and color, nipple and areola become bigger and darker • Compress nipples with finger and thumb, may express colostrum Abdomen • Inspect for skin changes: presence of Linea Nigra – darkening of the linea alba (Cause of uterus) • Inspect for Striae gravidarum “stretch mark” due to stretching of the abdomen, reddish or purplish in color and becomes silvery after delivery (The prevention for stretch mark is to put olive oil) • Associated risk factors are weight gain during pregnancy, younger maternal age, and family history • Palpate for the fetal movement “quickening” 10-12 fetal kicks per hour (Quickening – experience by 17 to 20 weeks or sometime other pregnant women feels it by 10 weeks ) • Braxton hick’s contraction – a normal painless contraction 3 Difference 1. Contract on timing – Braxton Hicks contractions are not in regular pattern and will go away (sumasakit pero nawawala), while true labor contractions will become regular and more frequent. 2. Gaining Strength – true labor contraction will go in intensity while Braxton Hicks is often described uncomfortable, not unbearable 3. Change it upper – if you change your activity such as walking or lying down, Braxton Hicks will often go away but labor not • Auscultation of fetal heart tone 120-160bpm - Can be detected through stethoscope by 18 weeks AOG - Can be detected through fetal Doppler at 10 – 12 weeks AOG Determining Fetal Age Naegele’s Rule - used only if patient has regular menses and is sure of her LMP. - If patient has irregular menses or does not remember her LMP: a) Uterine size b) Quickening c) First trimester ultrasound scan Example: January to March + 9 months + 7 days April to December - 3 months + 7 days + 1 year Jan 2, 2021 June 11, 2020 1 – 2 – 2021 6 – 11 – 2020 + 9 +7 - 3 + 7 + 1 10 - 9 - 2021 3 - 18 - 2021 Estimation of AOG of Pregnant Client • LMP • - days in the month of LMP • + days up to the present • ÷ 7 weeks Example: LMP = Nov 15, 2021 Present date = Feb 15, 2021 Nov 15 – 30 = 15 Dec = 31 Jan = 31 Feb = 15 92 ÷ 7 = 13.14 or 13 weeks and 1 day Mc Donald’d Rule - Determines AOG in month by measuring from - Symphysis pubis (cm) to the fundus Fundic Height in cm x 8 = AOG in weeks 7 Fundic Height in cm x 2 = AOG in months 7 Bartholomew’s Rule - Estimate age of gestation by the relative position - of the uterus in the abdominal cavity - 3rd mo. – the fundus is palpable above symphysis pubis - 5th mo. – the fundus is palpable at the level of umbilicus
NCMA217 RLE: PHYSICAL ASSESSMENT OF NORMAL PREGNANT CLIENT (MAM PACIS & SIR MIRADOR) J.A.K.E 3 of 4 - 9th mo. – the fundus is below xiphoid process - Fundic Height based on home-based maternal record by DOH • 5th month: 20 cm • 6th month: 21-24 cm • 7th month: 25-28 cm • 8th month: 29-30 cm • 9th month: 30-34 cm Haase’s Rule - To determine the length of the fetus in centimeter - Formula: • 1st half of pregnancy x square at month • 2nd half of pregnancy X at month by 5 • 1st half of pregnancy 2nd Half of pregnancy • 3 mos x 3 = 9cm • 6 mos x 5 = 30cm • 4 mos x 4 = 16cm • 7 mos x 5 = 35cm • 5 mos x 5 = 25cm • 8 mos x 5 = 40cm Johnson’s Rule - For estimation of fetal weight - Formula: • Fundic height in cm – n X 155 = fetal weight in grams • n = 12 if the fetus is engaged • n = 11 if the fetus is not engaged Example: 28cm not engaged 28cm - 11 = 17 17 x 155 = 2635gms 34cm engaged 34cm – 12 = 22 22 x 155 = 3410gms Signs of Pregnancy PRESUME mnemonics o Period absent (amenorrhea) o Really tired (fatigue) o Enlarged breast o Sore breast o Urination increased o Movement of fetus (quickening) o Emesis and nausea Possible signs Occurrence Sign Other possible cause 5 weeks Goodell’s Sign Pelvic congestion 6 - 8 weeks Chadwick’s Sign Pelvic congestion 6 - 12 weeks Hegar’s Sign Pelvic congestion 4 - 12 weeks + PT (blood) H-mole, choriocarcinoma 6 - 12 weeks + PT (urine) Pelvic infection 16 weeks Braxton Hicks Contraction Myoma 16 – 28 weeks Ballottement Tumor o Goodell’s sign - softening of the cervix, (increased vascularity, slight hypertrophy, and hyperplasia) o Chadwick sign - violet-bluish color of the vaginal mucosa and cervix (increased vascularity) o Hegar’s sign - softening of the lower uterine segment o Braxton Hicks Contraction - irregular, painless, and occur intermittently throughout pregnancy facilitate blood flow to the placenta PROBABLE mnemonics o Positive pregnancy test o Returning of the fetus (ballotment) o Outline of fetus can be palpated o Braxton hicks contraction o A softening of the cervix (Goodell) o Bluish color of vulva, cervix, vagina (Chadwick) o Lower uterine segment becomes soft (Hegar) o Enlarged uterus Possible Signs Occurrence Sign Other possible cause 5 – 6 weeks Fetus in UTZ No other cause 6 weeks FHT detected in UTZ 8 – 17 weeks FHT detected in doppler stethoscope 17 – 19 weeks FHT detected in fetal stethoscope 19 – 22 weeks Fetal movements palpated Late pregnancy Fetal movements visible FETUS mnemonics o Fetal movements o Electronic device detects fetal heart sounds o The delivery of the baby o Ultrasound detects the fetus o See visible movements of the baby Presumptive Signs Occurrence Sign Other possible cause 3 - 4 weeks Breast changes Pre-menstrual changes. Oral contraceptives 4 weeks Amenorrhea Stress, exercise, malnutrition, endocrine problems 4 - 14 weeks N&V Gastrointestinal disorder 6 - 12 weeks Urinary frequency Infection 12 weeks Fatigue Stress, illness 16 - 20 weeks Quickening Gas, peristalsis
NCMA217 RLE: PHYSICAL ASSESSMENT OF NORMAL PREGNANT CLIENT (MAM PACIS & SIR MIRADOR) J.A.K.E 4 of 4 Leopold’s Maneuver - Are a common and systematic way to determine the position of a fetus inside the woman's uterus. - Named after the gynecologist Christian Gerhard Leopold. - Also used to estimate term fetal weight. 1) LM 1 (Fundal Grip) - Palpation of the fundus to determine which fetal part occupies the fundus. - Fetal head should be round and hard - Buttocks soft and round 2) LM 2 (Umbilical Grip) - To determine which side is the fetal back, usually feels like a hard, resistant, convex structure. - Fetal extremities feels nodular and irregular 3) LM 3 (Pawlik’s Grip) - Suprapubic palpation using thumb and fingers just above the symphysis pubis to determine fetal presentation. - To know if it is cephalic or breech presentation - To know if the presenting part is engage or still floating “ballotment” - Palpation of the bilateral lower quadrants to determine fetal attitude. Auscultation of fetal heart tone: - 120-160bpm/110-160bpm - Can be detected throughstethoscope by 18 weeks AOG - Can be detected through fetal Doppler at 10 – 12 weeks AOG Extremities • Inspect hands and legs for edema • Palpate for pretibial, ankle and pedal edema o Physiologic edema is more common in women who stands a lot o Pathologic edema is often grade 3+ and often associated with PIH • Check for leg varicosities Grading Pitting Edema • 1+ Mild – Slight indentation, no visible swelling • 2+ Moderate – Indentation subsides rapidly, 10-15 sec. • 3+ Deep – Indentation remains for short time, last > 1 min. Legs look swollen • 4+ Very deep – Indentation lasts a long time; last 2-5 min. Legs look very swollen Genitalia • Inspect for the hair distribution and color • Scar from previous episiotomy or perineal laceration • Inspect the anal area for varicosities (hemorrhoids) • Inspect for vaginal discharge • Inspect for warts, foreign body and smell a) Chadwick’s sign – bluish to purplish color of the cervix due to increased vascularity b) Hagar’s sign – softening of the uterine isthmus and can be observed by 6th to 8th week AOG c) Goodell’s sign – cyanosis and softening of the cervix, may occur as early as 4 weeks AOG Concluding The Visit • Once the examination is completed instruct the client to get dressed • Review findings • Answer client’s questions • Advise necessary laboratory procedures that are needed • Reinforce the importance of regular check up • Record findings in the chart of the client