Maternal Child Health Prenatal Guide Home Care Visiting Guide
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Assessment
Items |
Norms |
Abnormalities |
Anticipatory
Guidance and Health
Teaching |
MCH
Nurse Required Further Actions |
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General Health |
- woman maintains preventive health
screenings and regular primary care and OB/GYN appointments |
-any abnormalities assessed from health
screenings or medical appointments are followed up with the appropriate care
provider |
-assure the pregnant woman has prenatal
care appointments and is able to get to them |
Assess vital signs, call medical care provider immediately if abnormalities exist |
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Vital Signs |
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1.
Temperature |
- temperature between 97 F and 100.3 F |
>100.4 (38C) – Check for other symptoms
such as leaking of fluid from the vagina, calf or leg pain, undue pain or
discomfort, burning with urination |
- teach to take temp and to call medical
care provider if >100.4 (38C) - Instruct in signs and symptoms of
infection |
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2.
Heart rate |
- Pulse rate between 50 and 100 beats per
minute (BPM) |
- Bradycardia <50/min; - Tachycardia >100/min; - Pulse rates >90 BPM could indicate
infection, hidden bleeding, or severe anemia.
Check for other signs such as hypotension, vaginal fluid or bleeding,
diaphoresis, or pale skin color. - FYI: Tocolytic
agents may increase heart rate and respiratory rate to above normal. |
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- If pulse rate is >90 BPM and other
signs are evident, call medical provider from client’s home immediately and
relate findings |
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3.
Respirations |
-respiratory rate, vital capacity &
inspiratory reserve volume remain essentially unchanged |
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4.
Blood pressure |
-blood pressure essentially same |
- Chronic hypertension is defined as a
blood pressure
measurement of 140/90 mm Hg or more on two
occasions before 20 weeks of gestation or persisting beyond
12 weeks postpartum. - Gestational hypertension has replaced
the term- pregnancy-induced hypertension- to describe women who
develop hypertension without proteinuria
after 20 weeks of gestation - Preeclampsia is a multi-organ disease
process of unknown
etiology characterized by the development of
hypertension and proteinuria after 20 weeks of gestation |
-teach signs & symptoms of elevated BP
and to call medical care provider if
experiencing any of these s & s -low BP may be due to orthostatic hypotension
or hemorrhage |
- BP of greater than 140/90 should be
repeated with the woman sitting & standing and then reported to the
medical provider - FYI: An increase
of 30 mm Hg systolic
or 15 mm Hg diastolic from baseline is no longer diagnostic for preeclampsia12
because similar increases are common in uncomplicated pregnancies, however,
any changes new or different should be immediately reported to the applicable
medical provider |
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Gastrointestinal System |
- Constipation & increased flatus
caused by progesterone on the smooth muscle of the bowel, changes in diet,
activity and exercise can also contribute - Heartburn caused by progesterone in
relaxing the cardiac sphincter along with decreased GI motility and the
compression of the stomach by the enlarging uterus - Nausea & Vomiting (usually dissipates
around 15 weeks) |
- Absent bowel
sounds - BM with pain,
fever, vomiting, signs & symptoms of obstruction or impaction - Frequency watery
diarrhea (concern dehydration) - poor weight gain
or obesity - Hypotension - Muscle cramping,
tetany, hypotonicity, weakness, and tingling of ends of fingers |
- Teach signs and symptoms of constipation,
diarrhea, heartburn and dehydration and when to call the medical provider - If bowel sounds are present but the woman
is constipated recommend exercise, roughage in diet, and increased
fluids. Call provider if no relief
with above - Teach how to track I & O as
applicable - Provide nutritional counseling - Encourage to take iron with large
quantity of vitamin C-enriched fluids |
- If bowel sounds are non-existent contact
medical care provider - If signs or symptoms of dehydration are
present call medical care provider |
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Urinary System |
- Average output is 1,500 ml per 24 hour
period via urinary tract |
- Decreased output
of less than 30 mL/hr, dysuria, frequency, pain
with urination accompanied by fever & chills |
- Teach recognition of signs & symptoms
of UTIs - Teach temperature taking - Encourage adequate fluid intake |
- If signs and symptoms of UTI contact
medical care provider from the woman’s home - If bladder distention is present contact
medical care provider from the home |
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Breasts |
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Increase in breast size -
Nipples & areola may become darker -
Toward end of pregnancy colostrum may be begin to appear |
- Masses in the
breasts - Extreme discomfort |
- Teach normal pregnancy related breast
changes - Encourage the woman to wear supportive
bra to promote comfort |
- Notify medical care provider if any
breast mass is found |
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Fundus or Uterus |
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Abdomen is soft & without masses -
After 22 – 24 weeks the uterus size is measured in cm from the symphysis
pubis to the top of the fundus; the number of cm should be equal to
approximately the number of weeks gestation, within 2 weeks -
Fetal heart tones should be within 120 – 160 BPM |
- Excessive uterine
irritability - Severe pain or
tenderness - Fundal height
consistently more or less than expected - Fetal heart tones
below 120 or above 160 BPM |
- Discuss Braxton Hicks contractions; True
Labor; Kick Counts - Teach the averages of fundal height
growth throughout the pregnancy |
- Contact medical care provider immediately
if labor contraction or rupture membrane is suspected before 37 weeks or with
any severe pain unrelated to normal labor after 37 weeks - Contact medical care provider immediately
if fetal heart tones are not WNLs |
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Extremities |
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Varicose veins in lower extremities, vulva or pelvis as a result of vascular
congestion in the pelvic region -
Pressure from the uterus may cause leg cramps or edema in the lower
extremities |
- Phlebitis - Painful Pitting
Edema - Extreme pain in
the calves |
- Teach signs and symptoms to contact
provider around DVTs & Edema/Hypertension |
- Notify provider if suspected phlebitis or
pitting edema in which the woman’s blood pressure is equal to or greater than
140/90 |
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Weight Gain |
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Psychological |
- May experience increased sensitivity,
fatigue, mood swings, frustration, vulnerability & some unusual thoughts
around foods & sex. |
- Acting out behaviors
that place the pregnancy at risk - Maladjustment to
body image changes |
- Teach the normal psychological deviations
that may arise during and/or throughout the pregnancy - Discussed “red flag” signs to immediately
contact the provider such as depression or dangerous behaviors, anxiety,
anorexia, exaggerated fatigue, delusions, hallucinations, hostility,
inappropriate thoughts or feelings |
- Contact provider from the home if any
“red flag” symptoms - Consult with provider to develop an
action plan & follow-up frequently |
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Intimate Partner Violence |
- Absence of partner violence (physical
& psychological/emotional) |
- Reports of any
verbal, physical, emotional, psychological abuse |
- Educate around partner violence - Teach social services/community service
availability for assistance - Discuss emergency intervention services - Address partner violence at every visit, as the woman becomes
more trusting of the visiting nurse she will more likely come forward with
any issues |
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Nicotine Dependence Drug Abuse Alcohol Abuse |
- Abstinence from smoking, alcohol &
drugs |
- Substance
use/abuse |
- Discuss adverse effects of substance use - Provide with outreach numbers &
community services available to assist with smoking cessation, drug &
alcohol abuse |
- Assist with connecting the woman with
appropriate community/social/medical services to assist her to be safe for
herself and her baby - Discuss with medical provider as needed |
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Prenatal Education / Anticipatory Guidance |
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Nutrition -
100 to 300 additional calories per day -
Provide written materials with USDA Food Pyramid
related to pregnancy found at http://www.mypyramid.gov/mypyramidmoms/pregnancy_nutrition_needs.html -
Discussed healthy snacks -
Provide appropriate referrals such as RD, WIC and other
community resources to assure appropriate/adequate nutrition is possible -
Prenatal Vitamin |
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Occupational Hazards |
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Common Discomforts of Pregnancy -
Nausea & vomiting, Constipation, Heartburn, Varicose
Veins & hemorrhoids, Headaches, Edema, Backache, Leg Cramps, Breast
Tenderness, Carpal Tunnel, Syndrome, Fatigue |
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Health
Care Maintenance: Activity
and exercise, Sexual activity, Dental Care, Immunizations, Prenatal Care Visits (Make sure connected
with provider, has access & transportation, discuss what to expect at
each visit and the recommended frequency of visits), Stress Management,
Support Network |
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References
Anderson, B., Marshak, H., & Hebbeler, D.
(2002, September). Identifying intimate partner violence at entry to prenatal
care: clustering routine clinical information. Journal Of Midwifery &
Women's Health, 47(5), 353-359. Retrieved September 28, 2008, from
MEDLINE database.
Chestnut, M (1998). High risk perinatal
home care manual.
Cox, J., &
Phelan, S. (2008, September). Nutrition during pregnancy. Obstetrics And
Gynecology Clinics Of
Dudley, D.
(n.d.). Normal Maternal Physiology:
Implications for Prenatal Care. University of
Edelman,
C. & Mandle, L. (2002). Health promotion throughout the lifespan.
Jarvis,
C. (2003). Physical examination &
health assessment.
Leeman, L., & Fontaine, P. (2008, July).
Hypertensive Disorders of Pregnancy. American Family Physician, 78(1),
93-100. Retrieved September 27, 2008, from Academic Search Premier database.
Sharps, P.,