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principles and practice
principles and practice Dual-Purpose Tool for Assessing Maternal Needs and Nursing Care A N N S . CAHILL, R N , BSN, M S N
T h e dud-purpose tool, a six-part fm,is used t o assess patient needs and t o assess nursing erne. On the f o r m the nurse records antepmtum, intrapartum, and postpartum information and her observations about the maternity patient and neonate-data that m e necessary for a quality nursing messment. T h e concept: Comprehensive nursing care is based on a thorvough assessment of the patient’s needs.
Defining comprehensive, quality care is a challenge faced by both the nursing and medical professionsa challenge which has recently received considerable attention. Before nursing care can be assessed, components of comprehensive care obviously must be defined. Nursing audits, which check for such items as the number of nursing notes and whether physicians’ orders were implemented, fall far short of this goal. Traditional audits do not even contain data on the high-level components of nursing care: assessing the patient, making a nursing diagnosis, and then intervening to accomplish a goal. T o determine whether nursing care is comprehensive is to determine whether nursing service has met all the patient’s needs for which nursing is responsible. T h e closer nursing service comes to meeting these needs, the more comprehensive is the nursing care. It follows then that comprehensive care is based on a thorough assessment of the patient’s needs. Function of Assessment Form T h e assessment tool presented here-a six-part form -can be used to assess 1 ) the maternity patient’s needs and 2 ) the comprehensiveness of nursing care (fulfillment of patient needs). When completed, the form contains all the antepartum, intraparturn, and postpartum information about the patient and her infant that the nurse needs to make a nursing assessment, calculate potential problems, and formulate appropriate interventions. (Form reproduced at end of article.) T h e form remains part of the patient’s permanent medical record. On Part I, the nurse records the maternal antenatal, labor, and delivery history. Much of this can be gathered from the patient’s record. Although contained in other areas of the chart, the information is not readily accessible to the nurse. Yet 28
it is vital in alerting her to potential problems, especially in regard to interaction and health of the mother and infant. For example, the information that the patient’s membranes ruptured over 12 hours prior to delivery alerts the nurse to the possibility of infection. T h e information that the mother did not seek prenatal care until late in her pregnancy may indicate rejection of the pregnancy and potential rejection of the child. T h e nurse who gathers this information should note on the patient’s kardex (card file system) all deviations from normal, appropriate nursing interventions, the patient’s response to each intervention, and finally, a nursing evaluation of each intervention. T h e information helps her formulate a comprehensive, individualized care plan. Data can be organized in the problem-oriented framework: T h e nurse lists her observations, both subjective and objective data, assesses each problem, formulates nursing interventions, and finally, evaluates each intervention. An example of subjective data: T h e infant appears unresponsive to environmental stimuli; consequently the mother is anxious. Objective data: T h e infant sucks only 30 seconds before falling asleep, sleeps 2 2 hours a day; his mother received 50 mg Demerol 40 minutes before delivery. T h e assessment: T h e baby is depressed secondary to Demerol administered during labor. T h e nursing intervention may be to reassure the mother that this behavior is transient and to encourage her to gently stimulate her baby. T h e intervention would be adjudged successful if the mother’s anxiety decreases. On the other four parts of the form, the nurse notes her observations in the following areas: Part 11: Significant maternal characteristics and behaviors January/February 1975 JOGN Nursing
Part 111: Significant infant behaviors and characteristics Part IV: Maternal-paternal-infant interaction. Emphasis here is preventative. T h e nurse observes their interaction, then provides anticipatory guidance to the family. She may also consult with, and refer the family to, other professionals. Part V: Physical condition of the mother, including data contained in traditional nursing notes Part VI: T h e family’s knowledge and education needs A nursing care plan is formulated for each part, and from this plan, nursing care can be evaluated systematically. If the patient receives antepartum care at the same institution where she delivers, data for the assessment could be collected antepartum. Data also could be collected antepartum b y the public health nurse. T h e form might then be filled out b y each appropriate nurse: antepartum, intrapartum, and postpartum. However, one nurse must be ultimately responsible for insuring that the form is completed and that the patient receives the appropriate nursing care before discharge. This nurse, most logically, would be the postpartum nurse, particularly in institutions utilizing primary nursing care. If the form is filled out on an ongoing basis, each nurse will not have to review the patient’s entire chart. Although filling out the form requires additional nursing time, it would insure that most significant patient needs are not overlooked. Inservice Education
T h e staff must be taught how to use this tool, particularly the part on parental-infant relationships. A single deviation from normal behavior may not indicate a problem; patterns are more significant. HowJanuary/February 1975 JOGN Nursing
ever, the most significant abnormal neonatal behaviors have not been defined. By following up patients, abnormal behaviors could be identified and preventative measures instituted. T h e staff may also need instruction in interviewing techniques and on the significance of some of the items on the form. Interpretations of patient behaviors may vary from nurse to nurse. Data are more reliable when the nurse charts specific behavior and refrains from generalizing. W h e n a new staff member begins using the tool, her assessments should be compared with those of a more experienced nurse. Staff conferences should be held frequently to review patient problems and to formulate and evaluate nursing interventions. Proper use of assessment tools, such as the form, helps to insure Comprehensive nursing care. Components of comprehensive care are explicitly defined and responsibility for its delivery is directly assigned. This tool would also seem to increase professional satisfaction because the nurse knows what her responsibilities are and can see the results of her nursing care. Address reprint requests to Mrs. Ann S. Cahill, RN, 1220 Bellaire Street, Denver, CO 80220.
T h e author is an Instructor in the University of Colorado School of Nwsing a t Denver. She received her M S N from the University of North Carolina, Chapel Hill. Mrs. Cahill was graduated with honors from Duke University, Durham, North Carolina, later worked as a staff nurse in the Medical Ceyiter, then as a Nurse Practitioner in the university’s Health Services Clinic. She is a member of A N A and Sigma Theta Tau. 29
ASSESSMENT OF MATERNAL NEEDS AND NURSING CARE 5. anesthesia and analgesia
1. Maternal History: Antenatal, Labor, and Delivery
A. Antenatal
1. first prenatal visit (data)
___-______
6. Apgar-
__-__
-______--__
2. preparation classes 3. follow-up visits (regular) ____
D. Placenta
4. lowest hematocrit
1. length of third stage
5. blood type
2. problems
6. serology
_
-
_
-
_
_
~
ASSESSMENT (actual and potential problems)
7. prescribed medications ____
8. other medications, drugs 9. significant family history
NURSING INTERVENTION (S) _______
__
10. significant personal history
RESU,LTS OF INTERVENTION (S)
~
_
_
_
_
_
.
~
~
11. past OB history II. Maternal Characteristics and Behaviors 12. problems with this pregnancy
~
A. Age -__-__--B.
Marital status----_-
C. Parity --__--D.
Ethnic group
E. Religion ----.---F.
Socioeconomic
G. Pregnancy planned
_____--_
H. Affect (smiles freq., etc.) B. Labor
1. date and time of onset _ 2. EDC ---__--.-Week
_ _ _ _ _ _ ~
~
________
_
-
_
I. Activity level (lethargic, nervous)
-
-
gest.
3. rupture of membranes (art. or spon.)
J. Expectations regarding infant ___
time
-
4. stimulation of labor (type)
-
K. Physical complaints ~ _ _ _ _ _
5. medications (drug, dose, route, and time) ____
L. Acceptance of femininity (Consider complaints such as those regarding absence from work; feelings about
6. fetal heart rate (pattern, lowest and highest) ~~~
breast-feeding; complaints of coital pain or dysmenorrhea.
~~~
7. signs of fetal distress
Note appearance.)
8. length of first stage9. significant patient behaviors----
-~
____-
______
ASSESSMENT __
NURSING INTERVENTION (S) C. Delivery
1. type __-_ 2. presentation
-
3. difficulties 4. length of second stage-_
30
__ ___ -_
-_ RESULTS OF INTERVENTION (S)
_______-
~
January/February 1975 JOGN Nursing
-
A. Frank anomalies -
-_
3. is happy about infant's sex ____
111. infant Characteristics and Behaviors
4. focuses more on self than infant ___
-
-
B. Prematurity, LGA, SGA C. Activity level
D. Infant's behaviors (already listed in Part Ill, C, D, E) in
_____-_
1. sleep patterns 2. random activity: minimal-moderate
response t o mothering behaviors------
___
extreme ___ D. Crying
1. number of hours __
-
ASSESSMENT ~-
___-
2. character: coarse, guttural weak, whining-
_
___
NURSING INTERVENTION (S)
E. Feeding
-
1. uncoordinated sucking 2. regurgitates __
amount RESULTS OF INTERVENTION ( S )
3. tonicity when nursing
_
ASSESSMENT _ _ _ _ _ _ - ~
NURSING INTERVENTION ( S )
V. Maternal Physical Condition
___________
A. Vital signs
_____
______
-
B. Fundus C. Lochia (color, odor, RESULTS OF INTERVENTION ( S ) __
# pads)-__-_---p--
_-
D. Breasts
___
__
-
1. type of feeding 2. engorge ment
_ _ _ _ _ _ ~_________
3. nipples
IV. Parental-infant Interaction
a. extended or inverted _ _ _____ A. Simulation of infant by mother or father
1. passive with little physical contact
b. condition ________
_______ E.
2. attempts t o elicit response _____
3. physically overstimulates infant (slaps, bites, hits, pokes)
-____
_________
B. Communication
1. calls baby by name _ _ ____________
__
F. Hemorrhoids -_____-__
ASSESSMENT __--____ ----_-_-_
2. calls baby "it" ____ 3. talks t o infant _ _ _ _ _ _ _ _ _ _ _ ~
4. looks at infant -________ ________
NURSING INTERVENTION (S)
_____
___________-
C. Attitude toward, and concern for, infant
1. immediately meets infant's needs
RESULTS OF INTERVENTION (S)
_________2. talks t o others about infant
January/February 1975 JOGN Nursing
-
_________ 3'
2. cord care _______
VI. Knowledge and Education Needs
..
3. circumcision care
A. Prenatal preparation 1. classes ____ 2. reading
_______
~ _ - _ _ _ _
___
3. physical (exercises, breast care)
__
__
_____-
4. diapering 5. temperature
6. diaperrash
7. pediatric followup
___-
F. Birth control
B. Breast care (breast feeding)
1. nipple care ~ _ _ _ _ _ _ _ _
1. type_-^-^-__---^__-^--
2. breaking suction----
2. understanding
_____--_______ __
3. alternating breasts
4. supplemental feedings
-____
G. Diet (nutritionist referral?)
5. law of supply and demand -
_____________
6. diet
H. Exercise
7. let down reflex8. supportive bra
-
9. technique of expressing milk __
10. drugs and breastfeeding
-__ ~
_
_ _ _ _ ~ _ _ _
11. weaning-
1. Supports _ 1. layette 2. father of child a t home?----
C. Bottle feeding 1. type of formula
1. received instruction postpartum 2. received written information ___________
-
--__
~
-~-_-______-
3. vitamins and iron
3. assistance from friends, relatives
____--_-_
2. preparation
_
___
4. professional assistance D. Feeding variables 1. rooting reflex
2. demand scheduling ___________3. length of feeding _-_______-____
4. amount of fomula per feeding
5. financial status ASSESSMENT
___--
~
5. positioning -
___--___--____-_ introduction other foods ____ ___----_-
6. burping 7.
NURSING INTERVENTION (S)
_____
-_
RESULTS OF INTERVENTION (S)
E. Infant care 1. bath
Remarks
_
32
_
_
~
January/February 1975 JOGN Nursing
T h e dud-purpose tool, a six-part fm,is used t o assess patient needs and t o assess nursing erne. On the f o r m the nurse records antepmtum, intrapartum, and postpartum information and her observations about the maternity patient and neonate-data that m e necessary for a quality nursing messment. T h e concept: Comprehensive nursing care is based on a thorvough assessment of the patient’s needs.
Defining comprehensive, quality care is a challenge faced by both the nursing and medical professionsa challenge which has recently received considerable attention. Before nursing care can be assessed, components of comprehensive care obviously must be defined. Nursing audits, which check for such items as the number of nursing notes and whether physicians’ orders were implemented, fall far short of this goal. Traditional audits do not even contain data on the high-level components of nursing care: assessing the patient, making a nursing diagnosis, and then intervening to accomplish a goal. T o determine whether nursing care is comprehensive is to determine whether nursing service has met all the patient’s needs for which nursing is responsible. T h e closer nursing service comes to meeting these needs, the more comprehensive is the nursing care. It follows then that comprehensive care is based on a thorough assessment of the patient’s needs. Function of Assessment Form T h e assessment tool presented here-a six-part form -can be used to assess 1 ) the maternity patient’s needs and 2 ) the comprehensiveness of nursing care (fulfillment of patient needs). When completed, the form contains all the antepartum, intraparturn, and postpartum information about the patient and her infant that the nurse needs to make a nursing assessment, calculate potential problems, and formulate appropriate interventions. (Form reproduced at end of article.) T h e form remains part of the patient’s permanent medical record. On Part I, the nurse records the maternal antenatal, labor, and delivery history. Much of this can be gathered from the patient’s record. Although contained in other areas of the chart, the information is not readily accessible to the nurse. Yet 28
it is vital in alerting her to potential problems, especially in regard to interaction and health of the mother and infant. For example, the information that the patient’s membranes ruptured over 12 hours prior to delivery alerts the nurse to the possibility of infection. T h e information that the mother did not seek prenatal care until late in her pregnancy may indicate rejection of the pregnancy and potential rejection of the child. T h e nurse who gathers this information should note on the patient’s kardex (card file system) all deviations from normal, appropriate nursing interventions, the patient’s response to each intervention, and finally, a nursing evaluation of each intervention. T h e information helps her formulate a comprehensive, individualized care plan. Data can be organized in the problem-oriented framework: T h e nurse lists her observations, both subjective and objective data, assesses each problem, formulates nursing interventions, and finally, evaluates each intervention. An example of subjective data: T h e infant appears unresponsive to environmental stimuli; consequently the mother is anxious. Objective data: T h e infant sucks only 30 seconds before falling asleep, sleeps 2 2 hours a day; his mother received 50 mg Demerol 40 minutes before delivery. T h e assessment: T h e baby is depressed secondary to Demerol administered during labor. T h e nursing intervention may be to reassure the mother that this behavior is transient and to encourage her to gently stimulate her baby. T h e intervention would be adjudged successful if the mother’s anxiety decreases. On the other four parts of the form, the nurse notes her observations in the following areas: Part 11: Significant maternal characteristics and behaviors January/February 1975 JOGN Nursing
Part 111: Significant infant behaviors and characteristics Part IV: Maternal-paternal-infant interaction. Emphasis here is preventative. T h e nurse observes their interaction, then provides anticipatory guidance to the family. She may also consult with, and refer the family to, other professionals. Part V: Physical condition of the mother, including data contained in traditional nursing notes Part VI: T h e family’s knowledge and education needs A nursing care plan is formulated for each part, and from this plan, nursing care can be evaluated systematically. If the patient receives antepartum care at the same institution where she delivers, data for the assessment could be collected antepartum. Data also could be collected antepartum b y the public health nurse. T h e form might then be filled out b y each appropriate nurse: antepartum, intrapartum, and postpartum. However, one nurse must be ultimately responsible for insuring that the form is completed and that the patient receives the appropriate nursing care before discharge. This nurse, most logically, would be the postpartum nurse, particularly in institutions utilizing primary nursing care. If the form is filled out on an ongoing basis, each nurse will not have to review the patient’s entire chart. Although filling out the form requires additional nursing time, it would insure that most significant patient needs are not overlooked. Inservice Education
T h e staff must be taught how to use this tool, particularly the part on parental-infant relationships. A single deviation from normal behavior may not indicate a problem; patterns are more significant. HowJanuary/February 1975 JOGN Nursing
ever, the most significant abnormal neonatal behaviors have not been defined. By following up patients, abnormal behaviors could be identified and preventative measures instituted. T h e staff may also need instruction in interviewing techniques and on the significance of some of the items on the form. Interpretations of patient behaviors may vary from nurse to nurse. Data are more reliable when the nurse charts specific behavior and refrains from generalizing. W h e n a new staff member begins using the tool, her assessments should be compared with those of a more experienced nurse. Staff conferences should be held frequently to review patient problems and to formulate and evaluate nursing interventions. Proper use of assessment tools, such as the form, helps to insure Comprehensive nursing care. Components of comprehensive care are explicitly defined and responsibility for its delivery is directly assigned. This tool would also seem to increase professional satisfaction because the nurse knows what her responsibilities are and can see the results of her nursing care. Address reprint requests to Mrs. Ann S. Cahill, RN, 1220 Bellaire Street, Denver, CO 80220.
T h e author is an Instructor in the University of Colorado School of Nwsing a t Denver. She received her M S N from the University of North Carolina, Chapel Hill. Mrs. Cahill was graduated with honors from Duke University, Durham, North Carolina, later worked as a staff nurse in the Medical Ceyiter, then as a Nurse Practitioner in the university’s Health Services Clinic. She is a member of A N A and Sigma Theta Tau. 29
ASSESSMENT OF MATERNAL NEEDS AND NURSING CARE 5. anesthesia and analgesia
1. Maternal History: Antenatal, Labor, and Delivery
A. Antenatal
1. first prenatal visit (data)
___-______
6. Apgar-
__-__
-______--__
2. preparation classes 3. follow-up visits (regular) ____
D. Placenta
4. lowest hematocrit
1. length of third stage
5. blood type
2. problems
6. serology
_
-
_
-
_
_
~
ASSESSMENT (actual and potential problems)
7. prescribed medications ____
8. other medications, drugs 9. significant family history
NURSING INTERVENTION (S) _______
__
10. significant personal history
RESU,LTS OF INTERVENTION (S)
~
_
_
_
_
_
.
~
~
11. past OB history II. Maternal Characteristics and Behaviors 12. problems with this pregnancy
~
A. Age -__-__--B.
Marital status----_-
C. Parity --__--D.
Ethnic group
E. Religion ----.---F.
Socioeconomic
G. Pregnancy planned
_____--_
H. Affect (smiles freq., etc.) B. Labor
1. date and time of onset _ 2. EDC ---__--.-Week
_ _ _ _ _ _ ~
~
________
_
-
_
I. Activity level (lethargic, nervous)
-
-
gest.
3. rupture of membranes (art. or spon.)
J. Expectations regarding infant ___
time
-
4. stimulation of labor (type)
-
K. Physical complaints ~ _ _ _ _ _
5. medications (drug, dose, route, and time) ____
L. Acceptance of femininity (Consider complaints such as those regarding absence from work; feelings about
6. fetal heart rate (pattern, lowest and highest) ~~~
breast-feeding; complaints of coital pain or dysmenorrhea.
~~~
7. signs of fetal distress
Note appearance.)
8. length of first stage9. significant patient behaviors----
-~
____-
______
ASSESSMENT __
NURSING INTERVENTION (S) C. Delivery
1. type __-_ 2. presentation
-
3. difficulties 4. length of second stage-_
30
__ ___ -_
-_ RESULTS OF INTERVENTION (S)
_______-
~
January/February 1975 JOGN Nursing
-
A. Frank anomalies -
-_
3. is happy about infant's sex ____
111. infant Characteristics and Behaviors
4. focuses more on self than infant ___
-
-
B. Prematurity, LGA, SGA C. Activity level
D. Infant's behaviors (already listed in Part Ill, C, D, E) in
_____-_
1. sleep patterns 2. random activity: minimal-moderate
response t o mothering behaviors------
___
extreme ___ D. Crying
1. number of hours __
-
ASSESSMENT ~-
___-
2. character: coarse, guttural weak, whining-
_
___
NURSING INTERVENTION (S)
E. Feeding
-
1. uncoordinated sucking 2. regurgitates __
amount RESULTS OF INTERVENTION ( S )
3. tonicity when nursing
_
ASSESSMENT _ _ _ _ _ _ - ~
NURSING INTERVENTION ( S )
V. Maternal Physical Condition
___________
A. Vital signs
_____
______
-
B. Fundus C. Lochia (color, odor, RESULTS OF INTERVENTION ( S ) __
# pads)-__-_---p--
_-
D. Breasts
___
__
-
1. type of feeding 2. engorge ment
_ _ _ _ _ _ ~_________
3. nipples
IV. Parental-infant Interaction
a. extended or inverted _ _ _____ A. Simulation of infant by mother or father
1. passive with little physical contact
b. condition ________
_______ E.
2. attempts t o elicit response _____
3. physically overstimulates infant (slaps, bites, hits, pokes)
-____
_________
B. Communication
1. calls baby by name _ _ ____________
__
F. Hemorrhoids -_____-__
ASSESSMENT __--____ ----_-_-_
2. calls baby "it" ____ 3. talks t o infant _ _ _ _ _ _ _ _ _ _ _ ~
4. looks at infant -________ ________
NURSING INTERVENTION (S)
_____
___________-
C. Attitude toward, and concern for, infant
1. immediately meets infant's needs
RESULTS OF INTERVENTION (S)
_________2. talks t o others about infant
January/February 1975 JOGN Nursing
-
_________ 3'
2. cord care _______
VI. Knowledge and Education Needs
..
3. circumcision care
A. Prenatal preparation 1. classes ____ 2. reading
_______
~ _ - _ _ _ _
___
3. physical (exercises, breast care)
__
__
_____-
4. diapering 5. temperature
6. diaperrash
7. pediatric followup
___-
F. Birth control
B. Breast care (breast feeding)
1. nipple care ~ _ _ _ _ _ _ _ _
1. type_-^-^-__---^__-^--
2. breaking suction----
2. understanding
_____--_______ __
3. alternating breasts
4. supplemental feedings
-____
G. Diet (nutritionist referral?)
5. law of supply and demand -
_____________
6. diet
H. Exercise
7. let down reflex8. supportive bra
-
9. technique of expressing milk __
10. drugs and breastfeeding
-__ ~
_
_ _ _ _ ~ _ _ _
11. weaning-
1. Supports _ 1. layette 2. father of child a t home?----
C. Bottle feeding 1. type of formula
1. received instruction postpartum 2. received written information ___________
-
--__
~
-~-_-______-
3. vitamins and iron
3. assistance from friends, relatives
____--_-_
2. preparation
_
___
4. professional assistance D. Feeding variables 1. rooting reflex
2. demand scheduling ___________3. length of feeding _-_______-____
4. amount of fomula per feeding
5. financial status ASSESSMENT
___--
~
5. positioning -
___--___--____-_ introduction other foods ____ ___----_-
6. burping 7.
NURSING INTERVENTION (S)
_____
-_
RESULTS OF INTERVENTION (S)
E. Infant care 1. bath
Remarks
_
32
_
_
~
January/February 1975 JOGN Nursing