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Assessment and Diagnosis in

Midwifery

Required Reading

http://www.internationalmidwives.org/
http://globalmidwiferycouncil.org/

Abbreviations and Symbols Commonly


Used by Health Practitioners
Activities
AMB ambulatory
CBR complete bed rest
Assessment Data
Abd abdomen
BP blood pressure
Diseases
AMI acut myocardial infarction
ASHD arteriosclerotic heart disease
Diagnostic Studies & Others
ABG arterial blood gases
BE barium enema

Symbols
> greater than
< less than
increase
increasing
decrease
Decreasing
Orders
ad lib as desired
AMA against medical orders
BM bowel movement
BP blood pressure
(C) with

Prescription Of Medication
b.d. twice a day
caps capsuls

VIDEO MIDWIFERY
EXAMINATION

ASSESSMENT
The initial database is obtained by means of a history and
examination.
Checklist for evaluating your use of the midwifery process

Assessment 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
COLLECTION
1. Legal
2. Complete
3. Accurate
4. Relevance
5. New

ASSESSMENT 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 (Temperature
PulseRespirationsBlood
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; etc

Understanding 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 loss
common symptoms are: nausea, insomnia, all kinds of
pain

The Five Attributes Of


Symptoms

P (Provokes) Including environmental factors,


personal activities, emotional reactions, or other
circumstances that may have contributed to the illness
Q (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 Structure
The words in explaining structure consists of the following:
consists of: terdiri dari
contains: mengandung
is fitted into: dipasang
is used for: digunakan untuk
is divided into: dibagi menjadi beberapa
is attached: ditempelkan
is supported: disangga
is covered: ditutup
is composed of: komposisi
are connected: dihubungkan
leads from: sambungan

Understanding Location
to be located/situated: terletak di
at the top of: di bagian paling atas
at the bottom: di bagian paling bawah
at the sides of: di samping

Understanding Measurements in
Midwifery
Look 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 twelfth

Look 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/Hg

DIAGNOSIS
J 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.
Source
Nursing, Midwifery and Allied Health
Professions Research Unit, University of
Stirling, Stirling, UK. h.l.cheyne@stir.ac.uk

EXERCISE

a) 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

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