Physical Assessment

Assessment and Diagnosis in MidwiferyRequired Readinghttp://www.internationalmidwives.org/http://globalmidwiferycouncil.org/Abbreviations and Symbols Commonly Used by Health PractitionersActivities AMB ambulatoryCBR complete bed restAssessment DataAbd abdomenBP blood pressureDiseasesAMI acut myocardial infarctionASHD arteriosclerotic heart diseaseDiagnostic Studies & OthersABG arterial blood gasesBE barium enemaSymbols> greater than< less than increaseincreasing decreaseDecreasingOrdersad lib as desiredAMA against medical ordersBM bowel movementBP blood pressure (C) withPrescription Of Medicationb.d. twice a daycaps capsulsVIDEO MIDWIFERY EXAMINATIONASSESSMENTThe initial database is obtained by means of a history and examination.Checklist for evaluating your use of the midwifery processAssessment data are documented:AccuratelyQuestionable data are validated.CompletelyUse of a systematic guide ensures that recorded data describe (1) the clients functional ability to meet each basic human need and (2) responses to health and illness.ConciselyIrrelevant data and meaningless generalizations are avoided.FactuallyClient behaviors are recorded rather than the midwives interpretation of these behaviors.PRINCIPLES OF DATA COLLECTION1. Legal 2. Complete3. Accurate4. Relevance5. NewASSESSMENT CONSIST OF:1. Assessing illness History: Patients Identity; Chief Complaint; HPI: History of Present Illness; PH (past History); Family History.2. Observation Vital Signs: T-P-R-BP (TemperaturePulseRespirationsBlood Pressure) and General Appearance.3. PE (Physical Examination): B1B 6 through Approach of IPPA (Inspection; Percussion; Palpation; Auscultation).4. Result of Diagnostic Test: Blood; Urine; Stool; X-ray; CTSCAN; etcUnderstanding Signs And Symptoms A sign of disease is something that a nurse can see or feel for herself. She can observe it. A symptom of disease is something that only the patient knows about. The patient tells the nurses about it.common signs: bruising; rash; swelling; weight losscommon symptoms are: nausea, insomnia, all kinds of pain

The Five Attributes Of SymptomsP (Provokes) Including environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illnessQ (Quality) What is it like? R (Region) Where is it? Does it radiate?S (Severity) How bad is it?T (Time) When did (does) it start? How long did (does) it last? How often did (does) it come?Understanding StructureThe words in explaining structure consists of the following:consists of: terdiri daricontains: mengandungis fitted into: dipasangis used for: digunakan untukis divided into: dibagi menjadi beberapais attached: ditempelkanis supported: disanggais covered: ditutupis composed of: komposisiare connected: dihubungkanleads from: sambunganUnderstanding Locationto be located/situated: terletak diat the top of: di bagian paling atasat the bottom: di bagian paling bawahat the sides of: di samping

Understanding Measurements in MidwiferyLook at these signs: + plus = equals times 0.506 naught point five oh six C degrees Centigrade B.P. blood pressure 1/12 one over twelve or one twelfthLook and read:Here is the description of a female patient: Height 1 m 68 cm Weight 75 kg Age 30 Temperature 37 C Pulse rate 75 beats per minute Blood pressure 120/80 mm/HgDIAGNOSISJ Adv Nurs.2006 Mar;53(6):625-35.Making the diagnosis of labour: midwives' diagnostic judgement and management decisions.Cheyne H,Dowding DW,Hundley V.SourceNursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, UK. h.l.cheyne@stir.ac.uk

EXERCISEa) You must give 0.5 gram of aspirin. You have 2 250 mg tablets and 10 50 mg tablets. Which do you give?b) You must order medicine for the prescription Penicillin 20 ml b.d. 3 days. How many ml of Penicillin will you need for the three days?c) You must give 20 mg of Prednisolone t.d.s It is available in 10 mg or 5 mg tablets. How many tablets must you give to the patient in one day?d) You must give 5 mg of a drug for every 1 kg of a patients body weight. He weighs 65 kg. How many mg do you give?e) A capsule contains 200 mg of a drug. How many gram of the drug are there in 10 capsules?f ) You must give one tablet q.d.s. How many do you give in three days?THANK YOU