OB Pathologic Assessment Tool o important because it

offers indications
Nursing Process and solutions to
 aid to increase the quality of possible
care thus increasing the level physiological and
satisfaction in individuals who psychological
receive our nursing care. problems
 also stimulates the nurses’  provides the healthcare
critical thinking, problem provider with salient
solving skills, and in actual information that may help a
clinical practice client’s risk for medical
concern
Steps  set of information is
obtained through interview
1. Assessment
Components in collecting subjective
 collecting data data
2. Diagnosis i. Client’s perception of health
 analyzing data to make in terms of the body system
professional nursing ii. Past health history of the
judgement patient - thorough way of
assessing
3. Planning iii. Family history - in terms of
heritage and genetically
 determining outcome transmitted diseases and
criteria and developing a illnesses
plan iv. Lifestyle and health
4. Implementation practices
v. Step by step physical
 carrying out the plan examination to have an
accurate result or outcome
5. Evaluation
2. Ongoing or partial assessment
 assessing whether the
outcome criteria have been  mini overview of the client’s
met and revising the plan body systems and holistic
health patterns as a follow
types of assessment up on his health status
1. Initial comprehensive assessment  problems are reassessed in
less depth to determine any
 starts with the collection of major changes from the
subjective data
 baseline data for us to assure
and ascertain the result
3. Focused or problem oriented
assessment
 thorough nursing assessment
of body system
 allows you to recognize
actual patient concerns and
complaints
 huge help in evaluating the
effectiveness of treatments
as well as the medication,
and nursing medical
interventions
 performed when a 3. Educate on laboratory tests
comprehensive data base
exists with a specific health
concern - thorough
assessment of a particular
client problem and does not
cover areas not related to the
problem
 more specific within the
scope and limitations
4. Emergency assessment
 very rapid assessment
performed in life-
threatening situations
 immediate diagnosis to
provide prompt treatment
Steps of Health assessment
1. Collect subjective data - data
gathered from the patient
2. Collect objective data - based on
your observations and analysis
II.
3. Validation of data
4. Documentation of data - to ensure
there is an evidence of care
Prepare for the assessment
1. Healthcare provider must review
the client’s record
 biographical data ( age, sex,
occupation, may include
demographic data)
2. Ask other health care team
members
 solicit additional
information
 educate patients about the
basic laboratory tests
4. Organize material needed for
assessment
 help the healthcare provider
to perform the procedure at
ease of assessment
efficiently and properly
CONTENTS OF OBSTETRICS
PATHOLOGIC ASSESSMENT
TOOL
I. General Information
 includes personal and
demographic data,
reason for
hospitalization
 ensures the validity of
the medical history
provided by the patient
History of Present Illness
 delivers the initial data
to produce the
 differential and  one evaluation of the
admitting diagnosis that female reproductive
will serve as a guide for system
the physician in terms of  treat information with
medical management, sensitivity and respect
intervention and even VII. Assessment of systems
decision making  one way to be sure with
 current medications, the assessment results
dosage timing and and will follow to
indications of use, vital provide a quality care
signs, weight (BMI and management:
interpretation) i. Head and Scalp
III. Past Obstetric/ Medical/  series of physical
Surgical history examination to
 records medical history ensure physical
for a thorough manifestation in
assessment relation to diseases
 identify people with and illnesses and in
higher than usual chance that it may guide the
of having common patient to have a
disorders such as heart treatment on the
disease, hypertension, possible underlying
stroke, certain cancers cause
and diabetics  more on the
IV. History of Family Illnesses prevention aspect
 hypertension , CAD,  provide advice on
CVD, Diabetes Mellitus, appropriate
Kidney disease, cosmetic treatments
tuberculosis, and cancer, and to improve the
others (specify) look, feel and
V. Obstetric history (pregnancy, behavior of the hair
labor, birth) ii. Eyes and ears
 can provide the family  uses inspection,
physician with useful obtaining
clues to this patient’s measurements, even
health risk palpitation and the
 more on the side effects use of your
or the possible ophthalmoscope
consequences if not iii. Nose, mouth, teeth and
attended throats
VI. Gynecological history
  the examiner can to the top of
elevate the tip of the the uterus
nose slightly to view  Circulation: in terms
the nasal septum, of the pulse and
the floor of the nose chances of bleeding
and even the vi. Respiration
turbinates  assessing the
 abnormalities patient’s breathing
presenting at birth in  check if the patient
these regions are is breathing
often indicative of adequately, if the
other anomalies airway is open,
check movement of
iv. Neck, lymph nodes and the patient, note
breast symmetry or lack of
 lymph nodes are symmetry in the
like veins that chest movement
collect and carry  aid us to determine
blood throughout the sufficiency of
the body but instead the respiration and
of carrying blood permits the
these vessels carry identification of
only the clear changes of
watery fluid called respiratory function
the lymph as a whole
v. Abdomen and circulation  gives to the
 Abdomen: fundal diagnosis and
height management of a
 used to rule variety of
out if a baby pathological
is small for conditions and and
its helps the physician
gestational evaluate therapeutic
age or large. interventions
Measureme vii. Food and fluid intake
nt is  gathered from the
generally patient
defined as a himself/herself
distance in through telling
centimeters something important
from the about his or her
pubic bone condition
  commonly solicited  height (measurement from base
during admission to top of a standing person-
and comprehensive inches, cm, feet or m)
examination  body built (composition, size
and type- ectomorph,
Subjective mesomorph and endomorph)
 includes usual diet: diet that  skin turgor (skin elasticity -
provides the human body the grasp skin between two fingers)
nutrients it needs to function  mucous membranes (lines
correctly various cavities in the body and
o High photogenic diets covers surface of internal
which is a plant diet that organs)
minimizes the
probability of provoking viii. Elimination
allergic reactions Subjective
 number of meals, last meal
intake  usual bowel pattern (pertains to
 appetite (desire to eat the characteristics and the
food)nausea frequency of bowel movement
 vomiting (ask patient for any and the possible time)
stomach discomfort and the  last bowel movement (pertains
sensation of wanting to vomit - to the last episode of the
if vomited ask patients how movement of food through the
many times, and what triggers it) digestive tract)
 dentures  character of stool (shape,
 allergy (immune system consistency, color, odor and
response to a foreign substance) frequency)
 heartburn or indigestion (made  amount of stool
by an acid reflux where some of  frequency of movement (number
the stomach contents are forced of occurrences of a repeating
back up into the esophagus) event per unit of time)
 mastication (swallowing  color of stool
problems)  history of GI bleeding (hallmark
 changes in weight sign for an underlying medical
 diuretic used (substances that condition)
promote diuresis thus increasing  hemorrhoids (inflamed veins of
production of urine. a person’s lower rectum)
 constipation (happens when
Objective bowel movements become less
 current weight (latest weight frequent and stool become
obtained) difficult to pass)
 usual voiding pattern (pertains to  ways of handling stress,
the number of times and financial concerns, relationship
possible case the patient status (assess the possible
urinated) emotional and psychological
 incontinence (lack of voluntary concerns)
control over urination or even  lifestyle, feelings of
defecation - urgency (commonly helplessness, hopelessness and
defined as an overwhelming powerlessness
need to get to a restroom for
release) xi. Safety
 chances of episodes of  Allergy
pain/burning/difficulty in  history of STD (specific date
voiding and type), blood transfusion
 history of kidney/bladder number (if used)
disease (we can get specific  history of accidental
assessment of the patient) injuries,
fractures/dislocations,
ix. Activity and rest arthritis/unstable joints, back
problems, changes in moles,
Subjective bleeding and prostheses
 usual activities/hobbies, leisure xii. Social Interaction
time activities,  family information
 limitations imposed by and other related
conditions (functional limitation support system will
activities such as walking, be obtained such as
sitting, reaching, etc.) patient’s marital
 sleep (number of hours, nap status, support
duration during day and sleeping person and the like
aids) xiii. Teaching and learning
 difficulty in sleeping  solicits the dominant
 feeling on awakening (may language that the
indicate disturbed sleeping patients use fir
pattern) effective
communications and
x. Ego Integrity adjustments
 education level is
Subjective obtained
 stress factors (common causes:
money, work,family
responsibilities and health
concerns)