This is the process of obtaining a comprehensive information from a client in order to make appropriate diagnoses for management.
Aims
· Assess patient/client within the midwifery services framework
· Obtain baseline information for informed patient care
· Identify the risk level of the client and the foetus
· Help with health promotion and management of the client
· Gain insight into client’s general health condition
Types
· Personal History
· Social History
· Past Obstetric History
· Present Obstetric History
· Gynaecological History
· Menstrual History
· Medical/Surgical History
· Family History
· Lactation History
· Nutritional History
· Contraceptive History
Requirements
· Maternal and Child Health Record Book (Manual or Electronic)
· Ball pen
· Comfortable chairs
· Conducive room or an enclosed area
Steps
1. Establish rapport (Refer steps)
2. Explain procedure (Refer steps)
3. Provide privacy and ensure client assume desired position
4. Ask about client well-being
5. Take personal history (name, age, town, house address)
6. Take social history (occupation, marital status, next of kin etc.)
7. Take medical/surgical history (past and present)
8. Ask about family history of known diseases such as hypertension, diabetes. Mental disorders, etc.
9. Take menstrual history: Age at menarche, cycle, duration of blood flow, LMP etc.
10. Take contraceptive history (type used, duration and side effects)
11. Take obstetric history (past and present)
12. Take lactation history (exclusive breast feeding and duration)
13. Explain to client the need to attend Antenatal Clinic and procedures involved
14. Ask about the number of previous pregnancies and what happened in each case
15. Ask for intervals between pregnancies and any ill health
16. Ask about nutritional history (eating pattern, diet, food taboos and allergies)
17. Enquire about number of tetanol injections received in life time
18. Ask about family support
19. Express appreciation to client for her cooperation
20. Record and report findings to Officer in-charge
0 Comments