Narm Test Specifications Iii. Maternal Health Assessment

Front 1

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including (list of implications to preg for each of following):
2. personal history, including religion, occupation, education, marital status, economic status, changes in health or behavior and woman’s evaluation of her health and nutrition

Back 1

RELIGION:
Different religious beliefs (such as amish, christian science, fundamental Christian, Jehovah's Witnesses, Judaism, Mennonite, Muslim, Scientology and more) can have defferent implications for pregnancy. Some implications include:
Use of less/no technology, use of medications that contain blood by-products(Rhogam--Jehovah's Witnesses), some instances they might refuse intervention, may refuse birth control, or certain types of birth control, sterilization and abortion are also prohibited in many religions, being careful about modesty (some more extreme than others), pictures etc. important for some many religions, alcohol, drugs, tobacco and caffeine are prohibited in many religions.(Frye, 615-26)

OCCUPATION/ECONOMIC STATUS::
Location of workplace(mother or husband) can carry certain environmental toxins (named specifically in other card), that could be potentially harmful to mother, fetus, and reproductive systems and should be temporarily transferred. Jobs requiring strenuous labor, heavy lifting and other physical stress should be temporarily transferred as well.

Financial hardship caused from a lack of or low-income occupation can cause undue stress during pregnancy.

EDUCATION:
- Lack of education can have many effects on the quality of life such as: occupation, social/economic standing, malnutrition, willingness to comply to your instruction, informed consent and prenatal edu

MARITAL STATUS:
- Single mothers may feel vulnerable from a lack of intrinsic support and may need extra nurturing from the midwife and encouragement to meet other expectant mothers for lasting friendship and long-term support.

CHANGES IN HEALTH/BEHAVIOR:
Changes in health and behorvioral lifestyle may be necessary for a healthy pregnancy, for instance if the mother is used to drinking alcohol or caffeine regularly, smoking, extreme excessive exercising or other dietary or lifestyle practices that may be effecting pregnancy.

WOMAN'S EVALUATION of HER HEALTH & NUTRITION:
Education, open-ended questions and counseling may be necesarry to help the mother realize what her current health is and what the optimal health could be, again with a gentle, non-judgemental and positive approach.

Front 2

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current
pregnancy, including:
3. potential exposure to environmental toxins(effects on fetus and fertility)

Back 2

The workplace, radiation, street drugs and pharmaceuticals are some of the places/things teratogenic chemicals can be found in.
Implications to preg and fetus include:
- Neonatal bromism
- Fetal death
- Neurologic damage
- potential embryofetoxic risk
- fetotoxic
- nuerobehavioral impairment
- congenital anomalies
- impotence
- infertility (decreased sperm count, motolity)
- increased miscarriages
- developmental disabilities
- sterility
(Frye, 294)

Front 3

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
4. medical conditions (list condition and implication, )

Back 3

MEDICAL CONDITIONS (and implications):
- HEENT- Severe headaches could indicate emotional stress, hypoglycemia, high BP, or disorders involving the vasculature in the brain.

- Cardiovascular/ Hypertension- pre-eclampsia, eclampsia (heart disease, cerebrovascular, congenital heart disease, mitral valve conditions)

- Respiratory- includes TB, asthma, pneumonia, bronchitis and other resp. problems (find out if they smoke or live with a smoker)-- some can become worsened by pregnancy

- Gastrointestinal- bypass, ostomy, colon disorders (crohn's), esophageal problems, gastric and colon cancers, stomach disorders/ulcers, small intestinal disorders and liver disease-- many of these disorders can become worsened in pregnancy and influence of hormones. They can interfere with nutrient assimilation as well as digestion in general.

- Urinary/Kidney- Demand on kidney function increases considerably during preg due to increase in maternal blood volume. Predisposes woman to UTI's and possibly pylonephritis/abnml kidney function and hypertension/preeclamspia (w/kidney disease)

- Neuropsych.- depression ,PPD, anxiety, schizophrenia, other psychoses, bipolar. Increased risk of recurence or relaspe may occur in pregnancy with previous condition.

- Infections- pregnancy may worsen current infection or make women more susceptible to other infections due to the suppressed immunity during pregnancy.

- Transfusion- If she has had one, were there adverse reactions? what was the reason? did she have any symptoms just after?(blood borne diseases)

- Surgeries- past surgery can give an idea of how the woman reacts to anesthesia and if she bleeds excessivley, a previous reproductive or abdominal surgery that may have caused scar tissue(could cause pain and pulling sensations)

- DES Exposure- Could cause reproductive abnormalties (even from grandmother)

- Thyroid/Diabetes- If diabetes ask what type, if it is insulin dependent (requires careful monitoring from physician and considerable risk is involved for fetus) or conrtolled by diet? Thyroid disease could be related to inadequate iodine intake, nodules could be cancerous.

- Anemia- predisposes women to anemia in pregnancy(bleeding and hemorrhage more serious)

- Varicosities/Phlebitis- varicosities can lead to thrombophlebitis,

- GYN: Herpes, STIs- Can make the woman more susceptible to other infections

- Abnormal PAP- increased growth of cells during pregnancy can make the woman more susceptible to cancer
(Frye)

Front 4

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
5. surgical history

Back 4

Hx of Surgery can give an idea of:
- how the woman reacts to anesthesia
- if she bleeds excessivley
- a previous reproductive or abdominal surgery that may have caused scar tissue(could cause pain and pulling sensations)
(Frye, 569)

Front 5

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
6. reproductive history including:
a) menstrual history

Back 5

Menstrual Hx
- Age of Onset- clues about hormonal balance if she started late (hormonal system may not be working as well) or very young age (body may have been overstimulated by hormones)

- Average length of cycle- could have an effect on length of gestation

- Regular/irregular- take into consideration when determining due date

- Flow, heavy/light- heavy may be associated with endometriosis, fibroids, or anemia

- Problems- such as intense cramps, PMS, endometriosis, fibroids, or other symptoms should be noted and treated or record info if treatment has already occured

- First day of LMP, Probable date of conception, quickening, and contraception used at time of conception all help to give clues for determining EDD.
(Frye, 558-60)

Front 6

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
6. reproductive history including:
b) gynecologic history

Back 6

GYN Hx: (some of these are discussed in other cards and will be skipped in this card)
- Infertility- psychological issues (fears of not belonging and obbsessing over s/s)
- DES exposure
- Vag infections (yeast, BV)
- STI's
- Chronic cervicitis
- Endometriosis
- PID
- Cysts
- Myomas
- Pelvic relaxations (cyst/rectocele)
- Polyps
- Breast masses
- Abnl Pap
- Biopsies
- GYN cancer
- GYN surgery
- Rape/abuse
(Many of these conditions should be treated, preferrably before pregnancy)

Front 7

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
6. reproductive history including:
d) childbearing history (list 10)

Back 7

CHILDBEARING Hx:
(- TPAL)Term, Parity, Abortions-(before or after 20 wks, spontaneous or induced), Living

- Child's name/DOB

- Place/Caregiver

- Wks gestation at birth

- Type of birth (vaginal, c-section, assisted, medicated natural, etc.)

- Complications(preg, labor or PP)

- Length of labor

- Personal feelings/experience of birth

- Wt., length, and APGAR or any complications with baby

- PP experiene, breastfed?
(Frye, 552-57)

Front 8

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
6. reproductive history including:
e) contraceptive practice

Back 8

Contraceptive Practice:
Inquire as to the type, effectiveness, experience--likes/dislikes, problems (allergies), length of use, partner experience/acceptance. Specific questions for different methods should also be asked (ie- when were hormonals stopped before conception, IUD-when is was removed any complications with)

Implications to pregnancy/risks with some contraceptives:

- Oral Contraceptives:
Should be stopped for at least one month before attempting to get pregnant (for optimal dating of pregnancy not teratogenic effect)

- Long-term Hormonal Methods (ie. injections or implants):
Should take several months before getting pregnant to resume regular ovulation pattern.

- IUD:
Risks if you get pregnant with IUD in situ are: intrauterine infection, sepsis, spontaneous abortion(if left in 50% if you take the IUD out spontaneous abortion goes down to 25%), spontaneous septic abortion, placenta previa, and premature labor.
(Varney's ch 16-20) (Fyre, 557-58)

Front 9

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
6. reproductive history including:
f) history of sexually transmitted infections (list 10, how it's passed to baby, and effects)
g) history of behavior posing risk for sexually transmitted infection exposure

Back 9

STI'S and implication to preg:

BACTERIAL

1. Syphilis- passed at 1month gestation, crosses placenta and causes fetal malformations--40% of untreated syphilis causes fetal or neonatal death from spontaneous abortion, stillbirth, or perinatal death. Another 40% of women give birth to babies with congenital syphilis (destructive disease ranging from crippling lesions in internal organs and long bones to death) Also causes placental malformations (large and yellow)

2. Chlamydia- passed at birth (birth canal), can be asymptomatic, effects eyes and lungs (pneumonia) of baby if not treated

3. Gonorrhea- passed at birth, effects eyes of baby if not treated

4. Bacterial Vaginosis- makes woman more susceptible to other STI's, also linked to premature birth

VIRAL

5. Herpes- (blister, fluid filled vesicle/lesions) transmitted at birth (50% of time with active infection) transmission during birth may result in neonatal death 60% of time or severe CNS or ocular damage. A primary infection is much more severe than recurrences.

6. HIV- vertical transmittion through placenta, at birth, and through breastmilk. Factors that increase transmission risk include: an elevated viral load, clinical disease progression, coinfection with STD's hep C and others, substance abuse, smoking, multiple sexual partners and unprotected sex, preterm birth, chorio and invasive fetal testing. Different treatment regim is usually indicated for HIV+ women when pregnant.
(NOTE: breastfeeding not contraindicated if you EXCLUSIVELY breastfeed along with antiretroviral therapy)

7. HPV(Human Papillomavirus)- (Genital warts can be asymptomatic) Transmitted at birth. Can cause growths on NB throat--RDS-- and is associated with cervical cancer.

8. Hepatitis B- Transmitted at birth (can be symptomatic and seen in 1 out of 10 asian women) 90% chance of transmission to baby, 90% of those babies will be carriers and 25% will eventually die form liver failure or hepatocellular carcinoma
(HCV is 5-6% transmission rate and HAV no transmission or other risks)

PARASITE OR FUNGAL:

9. Trichonomas- linked to premature birth--friable tissues

10. Candida- firable tissues, more susceptible to other STI's, premature birth and thrush in NB

Hx of behavioral risks to STD exposure:
- frequency and multiple number of sexual partners
- intercourse with same-sex or anal sex with opposite sex
- partner that is sexually active with others
- use of drugs, alcohol or intravenous drugs, sharing needles
- Hx of STD
- douche
(Varneys 439)

Front 10

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
6. reproductive history including:
h) history of risk of exposure to blood borne pathogens

Back 10

- Blood transfusion
- Use of medication that contains blood by products
- IV drug use- STD's
- Needle sticks and other sharps related injuries
- anytime an open wound/injury/bleeding comes in contact with your body, there is risk

Front 11

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
6. reproductive history including:
i) Rh type and plan of care if negative

Back 11

Rh type:

- Past pregnancies, what was care surrounding Rh-? Were there any complications? Were there any accidents or injuries during pregnancy?(possible isoimmunization)

- plan of care is to give Rhogam 300iu at 28wks and after birth (before 72 hrs PP)

Front 12

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
7. family medical history

Back 12

Family Hx and implications to preg:

Following conditions in family member predisposes woman to condition:
- Diabetes
- Hypertension
- Multiple Gestation
- Cancer
- Certain STD's

Ethnic origin can put woman at higher risk for certain conditions:
- Sickle-cell- African
- Thalassemia- B-Greek or Italian, A-Asain or Filipino
- Tay-Sach's or Canavan(leading to CNS damage and death)- Ashkenazi Jewish couples
- Cystic Fibrosis(lung disease and limited lifespan)- all Northern European descent
(Davis, 39)(Myles 271-2)

DES exposure in utero can cause (DES Daughters) cancer, reproductive structural differences, fertility problems and pregnancy complications

Front 13

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
8. psychosocial history
10. mental health

Back 13

Issues such as domestic violence/phys abuse, sexual abuse, drug abuse, eating disorders and other harmful habits can cause problems inpregnancy. Conditions such as stress and anxiety can be normal in pregnancy from hormonal changes. However, when stress level hormones are high and unecessary anxiety is present it can stretch the coping reserves and could prove crippling.
Depression ,PPD, anxiety, schizophrenia, other psychoses, bipolar. Increased risk of recurence or relaspe may occur in pregnancy with previous condition. Most conditions are likely to improve as pregnancy progresses. Psychological treatments and psychosocial interventions are effective for these conditions and caution should be exercised before pharmacological interventions are used during pregnancy, although medication may be necessary for the more severe illnesses. Those who develop a psychiatric illness later in pregnancy tend to get worse after birth into the PP period. (Myles 680-89)

Front 14

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
9. history of abuse(sexual & phyysical)

Back 14

SEXUAL:
Implications of sexual abuse in pregnancy and especially birth include:
- Fear of being "ripped apart" during birth
- resurfacing of previous abusive encounters during preg and especially birth
- Hyperemesis Gravidarum
- Exaggerated sypmtoms of pregnancy (more painful and inconvenient)
- Threatened premature labor
- Fear of being out of control or dependent (may hold laor at a certain point to protect genital area or baby)
- psychological/behovioral issues (controlling, unexplained pain with intercourse, hypersensitive to touch, over-willing to expose genitals and more)

DOMESTIC/PHYSICAL:
- women in abusive relationships are more likely to self-harm, develop eating disorders, or other symptoms of mental illness.(Myles682)

- Apart from obvious physical danger there are major emotional ramifications of physical abuse (mother may feel extremely protective of her unborn baby, keeping it inside as long as possible) (Davis, 101)

Front 15

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
11. Mother’s medical history:
a) genetics

Back 15

Following can put a mother/baby at greater risk:
- Racial/ethnic background
- Previous miscarriages, abortions, stillbirths or neonatal deaths
- relatives with genetic disorders, organ malfunctions or hearing/vision loss (Frye 566)

Front 16

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
11. Mother’s medical history:
b) alcohol use

Back 16

No amount of alcohol has been proven safe to intake during pregnancy. Heavy drinking has been associated with the following:
- Spontaneous abortion
- Low-birth-weight babies
- learning disabilities in children
- Infant mortality
- Birth defects (ie. fetal alcohol syndrome)
- reduces appetite and effects nutritional status
- decreased fertility

Fetal Alcohol Syndrome manifests as: prental and PP growth restriction, CNS abnlties in infant and child, and abnml facies. (Varneys 326-27) (Frye, 274-75)

Front 17

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
11. Mother’s medical history:
c) drug use(over-the-counter, recreational and prescription)

Back 17

- Over-the-Counter drugs can cause an array of issues from decreased liver to kidney function to PP hemorrhage, increased birth defects, stillbirth, and other issues.

- Recreational Drugs
There are many different kinds of recreational drugs, all of which have negative effects on maternal/fetal health in some way. Generally IUGR, fetal hypoxia, RDS, malnutrition, preeclampsia, infection, dysfunctional labor and hemorrhage are common effects of drug abuse. More specifically Amphetamines and Cocaine cause similar problems effecting the heart, brain/head/body size and defects and withdrawal syndrome. (exencphaly, macrocephaly, seizures, accute heart attack etc.) PCP is associated with infants with extreme sensitivity, tremulousness, increased muscle tone & even darting eyes. LSD can cause paranoia, tachy HR, abnml heart rhythms. Heroin causes menses, fertility and bleeding complications. It crosses the placenta rapidly, maternal/fetal withdrawal, risk of intrauterine demise, and SIDS. (Hyperactivity, RDS, fever, diuresis, convulsions and diarrhea characterize withdrawal in NB)

- Prescription drugs virtually all reach the fetus with the exception of pituitary & thyroid hormones, insulin, catecholamines and heparin. Have a Physician's Desk Reference (PDR) on hand to look up any drug and it's overall effects and possible implications for pregnancy.

(Frye, 282-90)

Front 18

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
11. Mother’s medical history:
d) tobacco use

Back 18

Cigarette smoke contains 68,000 toxins (including nicotine, hydrogen cyanide, heavy metals) all of which readily gain access to mothers circulation and cross placenta.(Frye, 266-71)
-associated risks include: IUGR, low birth weight, miscarriage, congenital heart disease, fetal hypoxia in labor, decrease fetal breathing movements, increased fetal and neonatal death, SIDS, placenta abruption, placenta previa, bleeding, premature rupture of membranes, constricts blood vessels which contributes to hypertension, elevates stress hormones in mother and baby, slows transmission of nuerologic signals, childhood cancer increased.
(Frye 266-71)

Front 19

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
11. Mother’s medical history:
e) allergies (food, drug and environmental/other)

Back 19

FOOD:
Food allergies will create aggravating symptoms as well as be poorly utilized by body. Allergies can frequently cause:
- asthma
- irritated cough or tickle of throat
- hay fever
- eczema
(Frye 256)

DRUG:
Important to know of any ddrug allergies and to record them clearly in your chart, particularly in case of a transport or if that drug is in your scope of practice.

OTHER:
Take note of any other allergies such as animals or other environmental allergies to keep in mind as care progresses.

Front 20

A. Obtain and maintain records of health,
reproductive and family medical history and possible implications to current pregnancy, including:
11. Mother’s medical history:
f) Father’s medical history
g) genetics
h) alcohol use
i) drug use
j) tobacco use

Back 20

- inquire as to relationship with mother
- his own birth and siblings births--his relationship/understanding of birth
GENETICS
- blood type and factor(RH-)
- age (risks greater after 40)
- body type and build
- any health issues of genetic origin, is he taking any medications or undergoing treatment for condition

ALCOHOL, DRUG, TOBACCO
All effect mens sperm and fertility.
Second-hand smoke around the pregnant woman has not been proven safe.
Excessive drug and alcohol abuse has been related to higher risk of physical abuse.

Front 21

B. Perform a physical examination,
including assessment of:
1. general appearance/skin condition(list NML and deviations from NML and their implications)

Back 21

GENERAL APPEARANCE:
- Apprapriateness of appearance for age
- obvious findings (ie. pallor, cyanosis, resp. distress, cough, etc)

SKIN CONDITIONS:
- pruritis(itch)
- rashes
- moles: any change noted
- lesions
- tendency to bruise
- general character(ie. dry oily)
- tempature
- color: pigmentation, pallor cyanosis, jaundice
- moisture
- turgor (assess dehydration from skin elasticity)
- scars
- patterns of injury, showing repetition of injury: fresh or in various stages of healing (e.g., cigarette burns)

Front 22

B. Perform a physical examination, including assessment of:
2. baseline weight and height

Back 22

HEIGHT:
- Have the mother stand up as straight as possible with her heels, buttocks and back against a hard surface and shoes removed before measuring. Opportunity to discuss posture, body mechanics, and exercise.

WEIGHT:(Frye 233, 417-419)
-When weighing someone, have them remove heavy clothing, shoes or accessories and balance their weight evenly between their feet.
- Pre-pregnant weight is most significant to keep in mind while assessing weight gain throughout pregnancy. Women underweight have little to no fat reserves to carry them through bouts of nausea or illness. Women with some extra pounds aren't at greater risk for problems as long as they keep a good diet throughout pregnancy.
- Low-maternal weight seems to have more adverse effects upon the fetus than high-maternal weight. (Varneys 599)
- Assuming that her starting weight was normal for her height and frame, an average gain is about a pound per week (could be more or less for over or underweight woman--as rule of thumb, 10lbs by 20 wks and about a pound a week thereafter). Many women are sensitive about their changing figure and should be reminded and reasurred that an ample weight gainis both desirable and essential for the baby's health and their own endurance, particularly during labor and immediate PP.
- Weight gain during preg is caused by increased water retention due to hormones, increased fatty insulation deposited over the belly and backside, increased weight in breasts, increased blood volume, plus obvious weight of enlarged uterus, including amniotic fluid, placenta and fetus.
- Eating disorders such as anorexia put the woman at higher risk for malnutrition and bulimia for hyperemesis gravidarium
- If the woman seems to be gaining weight rapidly, double check her diet and see if she's made any deleterious changes, or is taking in excess sugar (signaling a need for more low-fat protein sources)
- underweight women are at risk for anemia, preeclampsia, premature labor, prolonged labor, PP hemorrhage, poor recovery, and PPD. She must realize the importance of getting enough calories each day, discuss this thoroughly.
(Davis, 21, 67-68)

Front 23

B. Perform a physical examination,
including assessment of:
3. vital signs

Back 23

VITALS:
(pulse, RR, BP and temp) are obtained in the initial physical exam to ascertain normality and provide a baseline reading for comparison throughout pregnancy.
- BP--30/15 above or below baseline warrants investigation
- Pulse--normally 60-90 but can rise 10-15 points in pregnancy and still be normal. Irregularitiessuch as a bounding, weak or thready pulse are not considered normal (Frye, 420)
- RR-- 12-20 is NML, above or below is ABNML
- Temp-- Axillary 96.6-98.6, Oral- 97.6-99.6

Front 24

B. Perform a physical examination, including assessment of:
4. HEENT (Head, Eyes, Ears, Nose and Throat) including:
a) hair and scalp (head)

Back 24

HAIR/SCALP:
- general character (dry, oily)
- loss of hair, bold spots, wearing wig or not
- scalp infections, dandruff, lice, lesions,
- lumps

HEAD:
- Headaches: location, duration, when they occur, frequency, type of pain, severity, relief measures and their effectiveness, any known causative factors, associated symptoms,
- dizziness
- syncope(fainting)
- sinusitis
Observations:
- size, shape, contour, symmetry
- facial symmetry
- location and facial structures
- Involuntary movements
- Tenderness over frontal and maxillary sinuses
- injury of some kind
- moles and skin lesions
(Varneys, 40-41)(Frye, 427)

Front 25

B. Perform a physical examination, including assessment of:
4. HEENT (Head, Eyes, Ears, Nose and Throat)including:
b) eyes: pupils, whites, conjunctiva AND ears

Back 25

EYES:
- Pupils- observed for symmetrical dilation (ABNML if they are fixed and dilated or fixed and constricted)
- Conjunctiva- should appear thick, opaque, pink and higher vascular. Paleness indicates anemia while redness and purulent discharge indicates an infection.
- Whites/Sclera-- note color
- ROS and Ask if she has experienced any: blurred vision, blind spots in vision, double vision, spots, flashing lights, pressure/pain, photophobia(sensitivity to light), lacrimation(excessive tearing), discharge, redness, burning, glasses or contact lenses, injuries, disease or conditions.

EARS:
If the woman has hearing changes during pregnancy (ie. hearing loss), refer any woman with diminshed hearing to an otologist for evaluation.
- ROS and Ask if the woman is experiencing any: earaches, discharge, tinnitus(ringing in ears), Vertigo, pain or injuries.
- Observe outer ear for any deformaties, lumps or skin lesions.
- If any ear pain, inflammation or discharge is present, move auricle up and down, if this is painful an infection is most likey present.

Ear Exam w/ Otoscope:
- Look for NML ear wax and any discharge or foreign bodies
- As you advance speculum slightly downward and forward, ear drum should be visible as translucent greyish white membrane stretching over the small bones of the inner ear
- identify the short process and handle of the malleus, note its position
- find the cone of light
- note any inflammation, bulging or retractions.
(Frye 430-31)

Front 26

B. Perform a physical examination, including assessment of:
4. HEENT (Head, Eyes, Ears, Nose and Throat)including:
c) thyroid by palpation AND throat
5. lymph glands of neck, chest and under arms

Back 26

THROAT:
- ROS, observation and ask for: frequency of soar throats, if she smokes, previous surgery, hoarseness or voice change, difficulty with talking or speech, signs of infection in posterior pharynx, tonsillar fossae or pillars, inflamation, edema, bleeding exudate, pus patches, color, lesions, tumors, size, symmetry, and enlargement of tonsils.

THYROID:
- ROS, observation and ask for:
thyroid enlargement, Hx of goiter, enlargement or tenderness of any neck lymph glands--size, shape, consistency, and mobility of any nodes and glands--, ABNML pulsations, abnml range of motion or pain/stiffness, any injuries or deformaties to neck, excessive sweating, changes in secondary sex characteristics, changes in emotional lability, energy levels, HR, tremors, nervousness, known history of thyroid disease and medications. (Varney's 42-3)
- During preg the thyroid can be slightly more palpable than usual, an enlarged thyroid is otherwise a sign of hyperthyroidism. An enlarged thyroid accompanied with other S/S of thyroid problems should be followed up by a specialist. (Frye, 431)

LYMPH GLANDS:
enlargement or tenderness of any could indicate infection of some sort, fixed or hard could indicate malignancy, both require furthered investigation.(Frye, 426-7)

Front 27

B. Perform a physical examination, including assessment of:
4. HEENT (Head, Eyes, Ears, Nose and Throat) including:
d) mouth, teeth, mucus membrane, and tongue

Back 27

MOUTH:
-ROS, Observance of: bleeding, lesions, pain, tumors or edema, plaques, color, vascular spots, moisture (dry is ABNML)

TEETH:
ROS, Observance of:
any pain, decay, removal of teeth, bridges, dentures, number/missing teeth, caries, color(creamy white to pale yellow is NML), shape and position(straight and evenly spaced is NML

MUCUS MEMBRANE/GUMS:
- ROS, Observance of:
(smooth mucosal surfaces with sharp margins around teeth is NML) colors (redened and inflamed is ABNML), lesions, tumors, plaques, bleeding, edema, retractions, pus

TONGUE:
- symmetry, position, color(beefy red=inflamation, yellow=smoker) texture (dry smooth or fissured on top is ABNML), lesions, tumors, moistness, coating, mobility, deviation
(Frye, 428)(Varneys, 42)

Front 28

B. Perform a physical examination, including assessment of:
6. breasts:
a) evaluates mother’s knowledge of self-breast examination techniques, instructs if needed

Back 28

If your teaching of SBE has been effective the woman should be performing monthly SBE and should be able to do the following:
1. state importance of monthly SBE
2. State proper time for doing SBE
3. Demonstrate proper positionsfor inspection in front of mirror
4. State accurately what she is looking for during inspection
5. demonstrate proper position for palpation
6. demonstrate proper palpation method that covers ever part of breast including axillae, and gently compresses breast tissue against her chest wall
7. state what she is looking for during palpation
8. state what she is going to do if she finds something ABNML during inspection or palpation
(Varney's 1144)

Front 29

B. Perform a physical examination, including assessment of:
6. breasts:
b) performs breast exam

Back 29

OBSERVATION:
- Good lighting to see slight changes in breast contour, color, retraction signs, and nipple epithelium
- Inspect breast in 4 different standing positions:
1. With arms at side
2. With arms raised high over her head
3. With hands pressed agaisnt hips
4. Standing and bent forward from her hips with chin up and arms and hands extended toward you

ABNML Findings:
- asymmetry in breast contour, buldge or indentation
- retraction signs--skin dimpling, puckering or furrows
- nipple deviation (in direction it is pointing) or retraction or flattening of nipple
- shrunken breast
- edema, orange-peel skin
- dilated subQ veins(in non-preg women)
- elevation of skin temp or redness (non PP/breastfeeding)
- ulcerations
- excessive breast elevation and asymmetry with contraction of pectoral muscles
NIPPLE EPITHELIUM inspection- ABNML findings include erosion, ulceration , thickening, unusual roughness, redness--(woman not breastfeeding/sexually manipulated), crusting indicating dried discharge(non-pregnant, PP, or breasdtfeeding)

NML Findings:
- breasts unequal in size
- size of breasts small, large or pendulous
- accessory breast tissue (alone or any combo. of supernumerary nipples, areola, glandular parenchyma) this is a developmental anomaly with no pathological significance.
- inverted nipples (not retracted or deviated) are also of no pathological significance, but may be noted for furthered discussion pertaining to breastfeeding.

EXAMINATION:
All of the following methods begin with having the woman lie on her back with her arm above her head on the same side of her body as the breast you will palpate. (Place a small pillow under the shoulder of that same side if available). Palpate with the pads (flat portion) of your fingers, using gentle to-and-fro or rotary motion that gentle compresses breast tissue to chest wall. Every square inch of breast tissue must be palpated including beneath the nipple and axillae. If the woman has pointed out an area with a lump or tender spot, start exam by palpating opposite breast first to help differentiate NML from ABNML tissue.
1. Radial Method- Start on upper puter margin of the breast and proceed in circular , clock-wise fashion in ever-smaller concentric circles, ending with palpation beneath the nipple (you can also do it the opposite direction starting at bottom of areaola to outer margin of breast, ending underneath nipple)

2. Wheel-Spoke Method: start at upper outer margin and palpate in to the areola as though following the spoke of a wheel. Move in a clockwise motion around the breast, repeating the direction of palpation from outer margin to the areaola for each spoke of the wheel. End with palpation beneath the nipple. (you can also reverse this motion using the same method)

3. Transversing Method- dividethe breast into its medial and lateral halves, using an imaginary vertical line through the nipple as a dividing line. Start with the medial half at the level of the clavicle and palpate in a series of a parallel transverse lines from the nipple line to the sternum down to the caudal edge of the breast and again palpate in a series of parallel transverse lines, this time from the nipple line to the posterior axillary line back up to the level of the clavicle.

ABNML Findings:
- Coarse, grnular nodularity in a localized area
- loss of elasticity of nipples or breast tissue with increased firmness or thickening of skin texture
- Any mass note following: location, size, shape and contour, consistency, delimination (well defined, deliminated, poorly deliminated, or difficult to determine boundaries), and its mobility or movability(fixed to freely movable)

NML Findings:
- A transverse ridge, perhaps slightly tender, at the caudal edge of the breast
- fine nodularity throughout breast (NML tissue, lobules and glandular tissue)
- coarse nodularity generalized throughout the breast occuring during the premenstrual or menstrual phases of cycle
(Varneys, 1136-42)

Front 30

B. Perform a physical examination, including assessment of:
7. torso, extremities for bruising, abrasions, moles, unusual growths

Back 30

- Bruising/Abrasions: inquire where the bruises/abrasions came from (eliminating possibility of physical abuse or need for more help around the house or possible implications to fetal health), if she bruises easily (possibly anemic or other bleeding/clotting issues)

- Moles: considered ABNML and in need of referral if they are: different colors or spots within one mole or is not symmetrical when folded in half (jagged/unmatched edges)

- Any unusual growths or lesions should be further investigated and referred to physician

Front 31

B. Perform a physical examination, including assessment of:
8. baseline reflexes &
12. deep tendon reflexes of the knee

Back 31

CLONUS:
- Ankle clonus- Have woman lie down, place one hand under her knee and other under the ball of her foot and lift. Encourage woman to relax. Sharply dorsiflex the foot, maintaining pressure to keep it sharply flexed. Release your grasp and count any elicited beats of clonus. Repeat procedure on other foot. Discuss results with woman and compare any earlier findings.
- ABNML, if the foot beats 3 or more times, investigate further especially for S/S of preeclampsia

DEEP TENDON KNEE:
- Support under the knee with one hand, briskly tap below patella(kneecap) with reflex hammer and note the reflexive extension of knee. Grade reflex from 0-4+ (low could indicate disease, middle is NML, high could indicate anxiety or clonus)and repeat on other knee.
- If there is no reflex, repeat the procedure while the woman does an isometric contraction of other muscles(interlock fingers and pull apart with eyes closed)
(Frye434-35)

Front 32

B. Perform a physical examination, including assessment of:
9. heart and lungs

Back 32

HEART:
- location of point of maximum impulse(PMI)
- palpable thrills, rubs, impulses, shocks
- observing buldgings, heavings, pulsations
- AUSCULTATION of heart
--- Rate, rhythm, and quality or heart sounds at 4 valvular areas
--- extra sounds, murmurs, splitting, rubs, thrills

LUNGS:
- observe for: deformaties, symmetry, shape, masses, lesions, scars of shest structure and walls; intercostal and/or subclavicular retractions or bulging; equal resp movement, rate depth, rhythm, and type of resps
- Auscultation of Lungs (have woman take long slow breaths through mouth as you listen to the 6 sounds on chest and 7 on back of lungs):
---NML breath sounds(clear and unobstructed w/no extraneous sounds)
---- rales, rhonchi, wheezes, friction rub, adventitious sound
--- hearing nothing could indicate fluid in lungs, and underdeveloped or damaged section of lung
(Fyre 435-38) (Varneys 42-3)

Front 33

B. Perform a physical examination, including assessment of:
10. abdomen by palpation and observation for scars

Back 33

ROS:
- Anorexia, nausea, vomitting, heatburn, belching, hematemesis, pain, flatulence, gas, color, character or change in stools, jaundice, rectal itching , pain, burning, hemorrhoids, sphincter control, food allergies, hypoglycemic s/s?,

OBSERVE:
symmetry, shape contour, scars, distention, lesions, pigmentation, bruises, abnml pulsations

PALPATE for:
- Any unusual masses, lumps, rigidity
- enlarged inguinal nodes,
- femoral pulses (symmetric)
- hernias
(Varneys 43-4)

Front 34

B. Perform a physical examination, including assessment of:
11. kidney pain (CVAT)

Back 34

- Percuss the back for kidney tenderness in the costovertebral angle, by placing palmar surface of hand over either costovertebral angle and with other hand in a fist, with ulnar side of hand, strike into the back of your other hand. Note woman's reaction and note what (if any) degree of pain was elicited. Repeat on opposite side.

- Pain or tenderness suggests a possible kidney infection, however it also may occur with certain muscle or skeletal problems as well.
(Frye, 436-7)

Front 35

B. Perform a physical examination, including assessment of:
13. pelvic landmarks (Pelvimetry 5-steps)

Back 35

1. Assess depth of sacral curve (flat-android, easily feel entire curve-possible platypeloid)

2. Size of pelvic inlet, if it is deep, it is adequate
-follow it down to sacral promontory for the diagonal conjugate, which is thumb joint to fingertip(pre-measure)
- subtract 1.5cm SP thickness from this to get actual inlet dimension baby must navigate, termed the obstetrical conjugate---measurement of 10.5 cm or greater is considered adequate

3. Assess countour and distance between ischial spines.
- Note whether prominence is blunt or sharp and protruding
- interspinous diam should be at least 10.5 cm

4. Assess width of pubic arch angle, should be able to fit 2 fingers comfortably

5. Assess intertuberous diameter or outlet diameter, by making fist and gently pressing it between lowest point of ischial tuberosities, externally.
- (pre-measure fist) should be greater than 8.5cm
(Davis, 23-25)

Front 36

B. Perform a physical examination, including assessment of:
14. cervix (by speculum exam)

Back 36

PROCEDURE:
- Select the correct size of speculum, gather necessary equipment (gloves, lub, warmed speculum(if non-plastic), direct lighting, exam bed or table, underpad and drape.
- Encourage woman to relax in a semi-sitting or supine position, be senstitive to woman's emotional well-being throughout exam, let her know what you are doing at each step.
- Lubricate the speculum, carefully spread labia and introduce speculum with blades diagonal and closed.
- Carefully rotate blades to horizontal position with handle either up or down, always being sure of woman's comfort.
- Visualize vagina and cervix and note/observe: color, integrity of tissue, presence/absence of discharge, type and odor of discharge if present.
- Collect specimens according to protocol or as deemed necessary.
----PAP: with speculum in place (previously set-up necessary equip. such as liquid-base cervical solution(Thin-Prep), endocervical brush & spatula, or broom-like device), for spatula and brush, use blade end of spatula and obtain vag specimen from posterior fornix and spread specimen on the slide. Using the brush, rotate it to obtain endocervical specimen, spread specimen on slide and quickly apply cytology fixative over all specimens.
For broom-like device, with speculum in place, obtain a sample with broom by inserting the central bristles into endocervical canal deep enough for short bristles to fully contact ectocervix, gently push and rotate broom in clockwise direction 5 times. Rinse broom into bottom of vial 10 times and swirl it vigorously and place it aside or break of broom edge and leave it in container if directed.
Label and tighten cap on container for both of these methods.
----GYN Cultures: Obtain any gynecological cultures at this time also.
- Remove the speculum and help the woman up. Give her time to dress while you fill out necessary lab slips outside of the room.
(Pam Weaver)

FINDINGS
ABNML upon observing cervix: growths, nodules, masses, polyps, lesions, erosions, ulcerations, and infected nabothian cysts.
- Deviations of cervix to right or left could indicate pelvic masses or uterine adhesions
- Large, hypertrophied, or edematous cervix genereally indicates cervical infection
- Irregular shaped cervix may indicate presence of infected nabothian cyst (white or yellow pinpoints), which most frequently occur in the presence of chronic cervicitis (inflamation of cervix cause by an infection or injury, OB lacerations, mechanical devices, foreign objects, or allergic reactions.), all of which are ABNML.
- Discharge needs to be evaluated for its origin, if it is a continuation of vaginal infection deposited on the cervix, or pus of gonorrhea exuding from external cervical os.
- Friability of cervix (bleeding easily after obtaining Pap smear), frequently accompanies cervicitis.

NML:
- Color in nonpregnant woman is nmly pink. A presumptive sign of pregnancy (Chadwick's sign) is a bluish colored cervix due to increased vascularity.
- Position is NML if it is anterior, midline or posterior position determining a retroverted, midposition or anteverted uterus.
- Size of cervix in childbearing years is normally 2-3cm in diameter, slightly larger could indicate a grand multip, and slightly smaller a postmenopausal woman.
- A pregnant cervix can be more friable and is considered nml
(Varneys 1180-82)

Front 37

B. Perform a physical examination, including assessment of:
15. size of the uterus and ovaries (by bimanual exam)

Back 37

UTERUS
- Press up firmly on the cervix while using your other hand the fundus externally.
- 10 weeks- fundus barely clears pubic bone
- 12 wks- generally few cms above pubis
- 16 wks midway between pubic bone and umbilicus
- You can also assess the shape, contour, location and position of uterus.
(Davis 23)

OVARIES:
- moving over to one side, with both hands, feel for the ovary, which is about the size of an almond, it may not by felt. If it is clearly felt and enlarged that is ABNML.

Also ABNML is presence of: urethrocele, cystocele, rectocele, lack of perineal muscle tone, cysts, nodules, masses, growths, or any reaction of pain or tenderness during exam.
(Varneys 1183-87)

Front 38

B. Perform a physical examination, including assessment of:
16. condition of the vulva, vagina, cervix, perineum and anus

Back 38

VUVLA:
-- MONS VENERIS:
- Note hair growth pattern(secondary sex characteristic)
- presence of abrasions, scars, lesions etcs around prepuce and clitois
- presence of any foul or offensive odor
--LABIA MAJORA/MINORA & VESTIBULE:
- NML size and shape
- edema or swelling (possibly from Bartholin's abcess/cyst, or allergic reaction)
- inflamation, irritation (infection, itching or scratching area), discoloration, varicosities, lesions/vesicles/ulcerations(STI's), fistulas, fissures, cystocele, rectocele, any enlarged area or ABNML growths, odor, or discharge.
- vaginal introitus--check hymen or its remnants

CERVIX:
- color
- edema or inflamation
- discharge
- friability
- growths, nodules, polyps, scars, etc.
- size, shape, length and/or any dilation/effacement of os

PERINEUM:
- normalcy
- thickness, distance between introitus and anus
- ABNML scars, lesions, growths, etc.

ANUS:
- observe for inflammation, hemorrhoids, lesions, scars, etc
- Upon internal exam note normalcy, muscle tone, and check for presence of internal hemorrhoids or fissures
(Varneys1172-74) (Pam Weaver)

Front 39

B. Perform a physical examination, including assessment of:
17. musculo-skeletal system, including spine straightness and symmetry, posture

Back 39

OBSERVE
- Spine straghtness and symmetry, checking for scoliosis or deformaties
- Posture can also be discussed at this time and education on good posture, with strong core especially for pregnancy and childbirth.

ABNML: joint pain, stiffness, swelling, redness, heat, muslce weakness, cramps, pain, twitching, tremors, paralysis, injuries, edema of extremities, varicosities, Hx of arthritis,
muscular dystrophy, throbophlebitis, fractures, disk disease, sciatica
(Varneys 44)

Front 40

B. Perform a physical examination, including assessment of:
18. vascular system (edema, varicosities, thrombophlebitis)

Back 40

EDEMA:
- Observe extremeties for edema first

NML: no edema or ankle edema is physiological in pregnancy
ABNML: edema of upper shins, breastbone, or sacrum, pitting of +2 or greater is a sign of preeclampsia.
(Davis, 76-77)

VARICOSITIES/THROMBOPHLEBITIS:
- Observe for varocosities (veins whose walls have become prolapsed and dilated and therefore present a snake-like appearance rather than being smooth, straight or invisible) on thighs, and down legs (they may also appear on vulva or torso)
- If found, look for redness or swelling along the veins-- DO NOT massage or press firmly , as clots may become dislodged in the process)
- encourage women to wear support hose if they have varicosities(Frye 432)
- Check for Homan's sign (calf pain w/dorsiflex) for the presence of superficial thrombophlebitis (Davis 208)