Health Assessment

Introduction to Health Assessment &

Midwifery Care Process
By: Awol A. (MSc in Clinical Midwifery )
Dec, 2023

1 BY: Awol A.(CMW) For BSc MW Students

 Objectives
Describe the purpose of health assessment in Midwifery
Discuss the difference between health assessment in
midwifery and medicine
Explain the midwifery care process (MCP)

Describe components of the midwifery care process.

Carry out MCP.

Develop a Midwifery care plan

2 BY: Awol A.(CMW) For BSc MW Students

 Introduction to Health Assessment
It is a process undertaken by healthcare providers to
systematically collect subjective and objective
information about a patient.
to create a comprehensive database for use in planning
care.
To determine the patient’s current or ongoing health
status,
To predict risks to health and well-being, or
to identify health-promoting activities.

3 BY: Awol A.(CMW) For BSc MW Students

 Introduction to Health Assessment…
What is expected from midwives as examiners?
To gather the detailed, complete, and relevant data needed
to formulate a midwifery care plan that meets the needs of
the patient.
Knowledge
effective communication techniques and
Critical thinking skills
The 3 parts of the complete health assessment are
1. The interview/History Taking,
2. the physical assessment, and
3. Documentation of the findings.
4 BY: Awol A.(CMW) For BSc MW Students
 Introduction to Health Assessment…
These data include; Physiologic, Psychological, Socio-
cultural, Developmental; Spiritual etc data about the
client.
Thus a holistic data collection is performed.
Mind, body, and spirit are interdependent factors that
affect a person’s level of health.

5 BY: Awol A.(CMW) For BSc MW Students

 Introduction to Health Assessment…
"What distinguishes midwifery/nursing assessment from
physician assessment?“
The physician assessment
 focuses primarily on the client’s physiological status.
 Little attention is given to his/her psychological, socio-
cultural, or spiritual well-being.
Midwifery/nursing health assessment is a holistic health
approach.
 The concept of holism defines the whole as greater than
the sum of its parts.

6 BY: Awol A.(CMW) For BSc MW Students

 Introduction to Health Assessment…
Characteristics of holistic health
The whole is more than the sum of its part.
The whole determines the nature of its parts.
The parts can’t be understood if considered in isolation
from the whole.
The parts are dynamical interrelated or interdependent.
Holistic health care
It is a health care that acknowledge the interaction
between body, mind, spirit and environment.
Health
According to a holistic view, health is a harmonious
interaction between the body, mind and spirit.
BY: Awol A.(CMW)
7 For BSc MW Students
 Introduction to Health Assessment…
Disease
It is disharmonious in the interaction between body, mind, and
spirit.
Illness
It is feeling that results from the presence of disease.
Sickness
Social dysfunction (inadequacy) resulting from presence of
disease.
Risk factors
Are factors whose presence is associated with increase
probability that disease will develop later. Ex. the habit of
8
cigarette smoking is a risk factor for lung cancer.For BSc MW Students
BY: Awol A.(CMW)
 Introduction to Health Assessment…
Risk factors can be related to
Host – (human being ) –e.g Age , nutrition , sex
Environment – e.g pollution
Causative agents e.g species , disease resistance pattern

Risk factors can be classified as

Amenable to change – risk factor that can be changed
(modified)
Non-amenable to change - risk factor that can’t be
changed (modified)

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 Midwifery Care Process
Midwifery Care Process is A systematic way to assess,
identify a problem, plan, implement, and evaluate care
for individuals, families, groups, and communities.
It is dynamic, continuous, and circular when needed,
following an orderly succession of steps and requiring
critical thinking and various types and levels of decision-
making throughout.
 At times data collected or decisions made as well as
unanticipated outcomes will require re-visiting earlier
steps and re-planning with the woman

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 Purpose of Midwifery care Process
To identify clients’/patients’ health care needs

To establish midwifery care plan so as to meet those

needs
To complete the midwifery intervention designed to

meet the needs

To provide individualized care

To provide standard care for pts./clts.

16 BY: Awol A.(CMW) For BSc MW Students

 Characteristics of midwifery care process
Dynamic

Client-centered

Planned

Interpersonal and collaborative

Universally applicable

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 Characteristics of MCP Con…
Focus on problems and strengths

Humanistic and individualized

Cyclical

Outcome focused (results oriented) - is being tied to

what happens at the end of the process.

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 Components of MCP
 Assessment

 Diagnosis

 Planning

 Implementation

 Evaluation

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 I. Assessment
Midwifery assessment is the process of collecting
information from a variety of sources
 in order to understand the health status of the woman and
fetus/newborn.
This step is the foundation of the MCP
Is the systematic collection, organization, validation and
documentation of client data.
 a continuous process carried out during all phases of MCP.
All phases of the MCP depend on it.
Assessment is performed by systematic history-taking,
physical examination, and tests.
20 BY: Awol A.(CMW) For BSc MW Students
 Scope of Assessment
Determining the Scope of your Assessment

At the outset of each patient encounter, you will face the

common questions,
“How much should I do?” and

“Should my assessment be comprehensive or focused?”

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 Comprehensive Assessment
Appropriate for new patients in the office or hospital
Provides fundamental and personalized knowledge about
the patient
Strengthens the clinician–patient relationship
Helps identify or rule out physical causes related to
patient concerns
Provides a baseline for future assessments
Creates a platform for health promotion through
education and counseling
Develops proficiency in the essential skills of physical
examination
BY: Awol A.(CMW)
22 For BSc MW Students
 Focused assessment - problem-oriented assessment.
appropriate for
 established patients, especially during routine or urgent care
visits
Addresses focused concerns or symptoms
Assesses symptoms restricted to a specific body system
 Applies examination methods relevant to assessing the
concern or problem as thoroughly and carefully as
possible

23 BY: Awol A.(CMW) For BSc MW Students

 Sources of clinical data

1. Primary Source (Direct Source )

client: Usually best source

2. Secondary Source (Indirect Source)

Family Members

Client’s records such as:

Nursing/Medical Records

Laboratory Records etc.

24 BY: Awol A.(CMW) For BSc MW Students

 STEPS OF ASSESSMENT

The assessment phase of the MCP has four major steps.

1. Subjective data
2. Objective data
3. Data validation
4. Documentation

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 Subjective Vs Objective Data
Subjective Data
What the patient tells you
The symptoms and history,
from
Chief Complaint through
Review of Systems
Example:
Patient reports pressure over
her left chest “like an elephant
sitting there,” which goes into
her left neck and arm
26 BY: Awol A.(CMW)
Objective Data
What you detect during the
examination
All physical examination
findings, or signs
laboratory information, and
test data
Example:
Height- 170 cm, weight-
150 lbs, BMI 26, BP
160/80,
HR 96 and regular,
For BSc MW Students
 Data collection methods

Interviewing

Physical examination

Investigations

Laboratory

Imaging

27 BY: Awol A.(CMW) For BSc MW Students

 a) Interview
Is client -clinician interaction where by the clinician asks

and the client answers.

Phases of a midwifery interview

Preparatory phase

Introduction

Working phase

Termination
28 BY: Awol A.(CMW) For BSc MW Students
 I. Preparatory
 Is first step to be practiced.
 midwives collects background information from previous
charts if repeat case.
 Ensure environment is conducive

 Arrange seating
 Interviewer at 45° angle to patient

29 BY: Awol A.(CMW) For BSc MW Students

 II. Introduction
Midwives introduces self

Identifies purpose of interview

Ensure confidentiality /privacy

III. Working
Midwives gathers information

Excellent communication skills such as Active listening

,Eye contact ,Open-ended questions etc. should be

practiced.
30 BY: Awol A.(CMW) For BSc MW Students
 IV. Termination
 Inform patient when nearing end of interview

 Ensure patient knows what will happen with the information.

 Offers patient chance to add anything

31 BY: Awol A.(CMW) For BSc MW Students

 II. Diagnosis
Diagnosis is the systematic process used by health care
providers to determine which condition explains a
client’s signs and symptoms.
Data's from assessment analyzed to inform decision-
making.
It is the conclusion of assessments.
Midwife create a list of differential diagnoses
hypothesis testing, the midwife accepts or rejects a
particular differential diagnosis
Finally, the midwife then selects the most likely
diagnosis,
32 BY: Awol A.(CMW) For BSc MW Students
 III. Planning
Planning is the third phase of the MCP
Is the determination of what can be done to assist the
client, and involves
setting of goals and objectives,
 judging priorities, and
designing methods to resolve actual and potential
problems.
 Setting goals & objectives - The 1st stage in planning , which is
 derived from the diagnosis and
 Established for each diagnosis listed.
 should be realistic and attainable

33 BY: Awol A.(CMW) For BSc MW Students

There for in planning;
Priorities are set;
Goals are determined;
Expected outcomes are developed;
Midwifery care plan is formulated
Selection of intervention
Midwifery care plan
It is a written document that guides the midwifery care
provided to the patient.
Contain all components of MCP
34 BY: Awol A.(CMW) For BSc MW Students
 IV: Implementation
It refers to the action initiated to accomplish the defined
goals and objectives through intellectual, interpersonal
and technical in nature.
Putting midwifery care plan into action.
Includes
Performing, directing or assisting the performance of
activities of daily living (ADL), activities ambulation,
eating, dressing, bathing, brushing, grooming, and
toileting.
Counseling and teaching the client or family
Providing direct care

36 BY: Awol A.(CMW) For BSc MW Students

 V: Evaluations
The final phase of the midwifery care process
Measures the client’s response to midwifery actions and
the client’s progress towards achieving the goal and
expected outcomes.
It may lead to reassessment, which in turn may result in
the MCP beginning all over again.
The main questions to ask in the evaluation are:
Were the goals and objectives met?
Were there identifiable changes in the clients’
behavior?
If so why? If not why not?

37 BY: Awol A.(CMW) For BSc MW Students

 Summary of the midwifery care process

38 BY: Awol A.(CMW) For BSc MW Students

 THANK YOU

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