Guideline 1: Prenatal History and Physical Assessment: Nursing
Purpose
A thorough nursing assessment of the client's physical and emotional health will provide essential information to enable the nurse to develop a care plan that supports the most appropriate interventions to promote a healthy pregnancy and optimal birth outcomes.
Process
A comprehensive nursing assessment should be done at the initial prenatal visit. It may not be possible to complete the full assessment in one visit, and not all of these issues may be pertinent to every client. However, as an important component of the nursing process, the systems delineated in Table 1 should be considered for assessment in a timely manner. Some more sensitive areas might require waiting until rapport is established to assess (e.g., IPV and substance use). Some of these areas may be assessed through therapeutic conversation, rather than hands-on assessment, per nurse's discretion. Any areas that require further assessment and follow up should be noted and explored in further visits as soon as possible. Physical and mental health concerns should have continued follow up at subsequent visits as needed.
The body systems to consider for the assessment are listed in Table 1. Blood pressure and weight should be monitored at each prenatal visit (see also Perinatal Blood Pressure Assessment Guideline). If implementing agencies expect nurses to perform clinical care skills not included within these guidelines, the implementing agency is responsible for ensuring that appropriate guidelines and training are in place to support the necessary nurse competency in those skills. (e.g. fluoride varnish, prescription or over-the-counter medication administration, immunizations).
While clients with chronic health issues (e.g. asthma, renal disease, cardiac disease, orthopedic issues) may need some additional case management services, clinical care responsibilities lie with the medical care provider. Signs and symptoms of concern, or medical concerns raised by the client, should be referred to the appropriate medical care provider, and the referral should be documented (see Table 1 guidelines for when to refer).
See the Pregnancy Warning Signs in the Prenatal Education Table of the Babies First! Manual for list of specific signs to report to provider immediately.