Component Task: General Examination of a Pregnant Woman at the Ante-Natal Clinic

This is the first assessment of the pregnant client/woman at the Antenatal Clinic through the use of all the senses and appropriate tools.

Aims

·         Obtain baseline data for informed patient care

·         Detect any abnormalities

·         Treat any identified anomalies

·         Prevent complications

·         Give appropriate health education to the client

·         Assess nutritional status

Types

·         General Assessment

o   General appearance

Requirements

Set a trolley containing the following:

a.      Top shelf

·         Gallipot with cotton wool swab

·         Kidney dish

·         Sterile container for urine specimen

b.      Bottom Shelf

·         Mackintosh

·         Gown

·         Bed linen

·         Sphygmomanometer and stethoscope

·         Foetal stethoscope/Electronic foetal monitor

·         Urine dipsticks

·         Clinical thermometer

·         Measuring tape

·         Sanitary pad

·         Torch light

·         Disposable gloves

·         Ballpoint pen, pencil

·         Weight scale

·         Height scale

·         Examination table

c.      Others

Steps

1.        Establish rapport (refer steps)

2.      Explain procedure to client (refer steps)

3.      Ask the client to empty her bladder and obtain midstream urine

4.      Provide privacy and perform hand hygiene

5.      Observe general appearance of client

6.      Measure height and weight

7.       Check temperature, pulse respiration and blood pressure

8.      Assist client to undress and wear gown

9.      Help client to adopt dorsal position

10.    Examine scalp and face

11.      Examine neck, upper limbs and axillae

12.    Examine breasts and teach client breast self-examination

13.    Expose and inspect abdomen

14.    Measure symphysio-fundal height

15.    Perform fundal and lateral palpation

16.    Instruct client to bend her knees slightly and breathe slowly through the mouth

17.    Perform pelvic palpation and assess head descent

18.    Listen and count foetal heart rate for one minute

19.    Examine the vulva for any abnormalities

20.  Instruct client to lie on her side and examine the back

21.    Examine the lower limbs

22.  Communicate findings to the client

23.  Express appreciation to client for her cooperation

24.  Help her out of bed and assist to re-dress

25.  Dispose off and decontaminate used items

26.  Perform hand hygiene

27.  Record and report findings