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MIDW127 - Beginning the Journey > Week Five > Flashcards

Flashcards in Week Five Deck (20):

Types of Patient Assessment

Must be systematic to ensure nothing is missed
- Primary & Secondary Survey
- Functional Health Pattern
- Systems Assessment
- Head to Toe


Assessment Techniques

- Inspection → Look
- Auscultation → Listen
- Palpation → Feel



Take time to stop and look, what are you looking for?
- Skin colour (Pink, Grey, Cyanosed, Pale, Flushed)
- Injuries (Deformities, Swelling, Bruising, Lacerations, Foreign Bodies)
- Oedema
- Discharge (Ears, Nose, Vagina etc)
- Symmetry (Facial Features, Chest rise and fall)



- Some sounds are audible to our ears (Gurgling from upper airway congestion)
- Blocks out extraneous sound and channels sound to your ears
- Slope earpieces towards your nose
- Bell (Soft/low pitched sounds - heart sounds, murmurs. Hold lightly against skin)
- Diaphragm - used most often (High pitched sounds - breath/bowel sounds. Hold firmly against skin)
- Listen for Foetal Heart Rate (FHR) through abdominal wall



Adds and confirms the data already gathered
- Assesses texture, temperature, moisture, organ location, swelling, pulsation, rigidity, crepitation, masses and tenderness (palpate tender areas fast).
- Also determines lie, presentation and attitude of foetus.


Primary Assessment

- Identifies life threatening problems
- As problems are identified they are immediately addressed before continuing with assessment
- Airway, Breathing, Circulation, Disability



- Assess if airway patent
- Is patient talking, hoard voice (oedema), any obstruction (loose teeth, vomit, rolled back tongue)



- Is patient breathing spontaneously
- Chest rise and fall (Symmetry & Depth)
- Skin Colour (Pink, Cyanotic or Grey)
- Respiratory Rate & Rhythm (Normal, Fast or Slow, Regular or Irregular)
- Respiratory Effort (use of accessory and/or abdominal muscles



- Assess Pulse (Quality & Rate)
- Assess Skin colour, temperature, and diaphoresis (sweating)
- Inspect for any obvious bleeding



- Assess patient's level of consciousness (AVPU Mneumonic)
A - Is patient alert and responsive?
V - Does the patient respond to verbal stimuli?
P - Does the patient respond to pain?
U - Is the patient unresponsive to painful stimuli?
- Assess pupil for response to light, size, equality and shape


Head to Toe Assessment

- Take a full set of vital signs
- Observe patient's general appearance
~ Gait/posture/mobility
~ Hygiene
~ Dress (kept/unkempt)
~ Odour (alcohol, fruity breath, urine, faeces)
~ Colour (pink/grey/pale/flushed/cyanotic)
- Work systematically inspecting all areas, palpating for tenderness and deformities and auscultating where applicable
~ Head and face (eyes, ears, nose)
~ Neck
~ Chest (auscultate breath and heart sounds)
~ Abdomen and flanks (auscultate bowel sounds)
~ Pelvis and Perineum
~ Extremities (also assess motor strength, power and sensation)
- Finally inspect and palpate the patient's posterior surfaces


Dating the pregnancy

Naegle's Rule
- Add 7 days and 9 months to the date of the first day of the Last Normal Menstrual Period (LNMP)
- Presumes a 28 day cycle


When Assessing Pregnant patients, Remember:

- To avoid compression of the aorta from the gravid uterus, pregnant women should not be assessed while laying supine (on their back)
- A wedge should be placed under the right hip to displace the uterus to the left
- Additionally, management of the pregnant woman involves two patients, however assessment is the same as for the non-pregnant person using the primary and secondary surveys


Primary Survey in Pregnant Ladies

- Airway
- Breathing & Ventilation
- Circulation & Control of Bleeding
- Disability (Neurological Assessment & Foetal Status)


Secondary Survey in Pregnant Ladies

The primary survey should be followed by a thorough secondary survey with head to toe examination of the woman
- Abdominal Palpation
- Foetal Heart Rate
- Fundal Height
- Foetal Lie


Vital Signs Indicate

- The body's physiological status
- Response to physical, emotional & environmental stressors
- Sudden changes in patient's condition, or
- Gradual progressive changes over time


Vitals - MIdwife's Responsibility

- Know the normal ranges for vital signs
- Know the patient's medical history and treatment regime
- Use an organised, systematic approach
- Minimise environmental factors that can affect vital signs
- Accurately record findings
- Analyse findings
- Verify and report significant changes


Blood Pressure

- Force exerted by blood on the vessel walls
- Measurement usually reflects arterial wall pressure
- Ensures oxygenation of vital organs
- Increases with ventricular contraction (systole)
- Decreases with ventricular relaxation (diastole)


Normal Maternal Values

- 100/60 → 140/90
- 120/80 average
- NICE & WHO define:
- Hypotension → systolic below 100
- Hypertension → Systolic above 140, diastolic above 90


Factors influencing BP

- Blood volume
- Age
- Smoking
- Pain, Anxiety, Stress, Fear
- Heart Rate
- Exercise
- Weight
- Alcohol
- Eating
- Hereditary Factors