CLIENT ASSESSMENT DATA BASE
Activity/Rest
Malaise, fatigue
Generalized weakness
May report difficulty sleeping
Poor muscle tone/muscle wasting
Circulation
May be jaundiced
Elimination
Dysuria, urinary frequency, decreased urine output, hematuria
Food/Fluid
Nausea, vomiting, anorexia, weight loss.
Tongue may have visible lesion or sore (hairy leukoplakia seen in AIDS).
May report indigestion, altered taste.
Loss of subcutaneous fat.
Poor skin turgor.
Pain/Discomfort
Backache, flank pain, colicky pain noted with acute pyelonephritis.
Chest pain may occur with tuberculosis.
Severe itching, burning pain with lesions.
May complain of pruritus with active (infectious) hepatitis A or B.
Respiration
Dyspnea with exertion.
Cough may be productive of thick/purulent/blood-tinged sputum or may be nonproductive.
Crackles (rales), wheezes, bronchial breath sounds; tubular breath sounds, diminished/absent breath sounds over areas of pleural effusion or pneumothorax (tuberculosis).
Safety
Temperature elevation dependent on type of infection, e.g., low-grade in cystitis, high fever in pyelonephritis
Chills, night sweats
History of UTI
Positive cultures, elevated titers, positive screening for infectious disease
Exposure to body fluids or blood products through professional practice or through receiving a transfusion parenterally as a patient; carrier of group B beta-hemolytic streptococci (GBS) or of hepatitis B virus (HbsAg, anti-HBcAg)
Exposure to infectious agents through employment/environmental contact
Sexuality
May have history of early trimester pregnancy loss(es).
May currently have, or have previous exposure to, numerous heterosexual/bisexual partners, which increases risk for exposure to HIV and STDs; sexual partner may be hemophiliac, necessitating blood transfusions and placing him at risk for acquisition of HIV.
Vaginal discharge may be frothy, gray-green (trichomonal infection); whitish (candidal infection); thin, watery, yellow-gray, foul-smelling, “fishy” (Gardnerella vaginalis infection).
Strawberry patches on vaginal walls/cervix (trichomonal infection).
May have visible perineal or genital warts, lesions, or chancres.
Fundal height may not be AGA, possibly indicating IUGR associated with rubella or toxoplasmosis, or may correspond with gestational age of less than 37 wk, indicating increased risk for GBS.
Membranes may rupture prematurely (PROM).
Social Interaction
Immigrants from Africa or Haiti may have increased risk of AIDS; immigrants from Southeast Asia, Central America, or the Caribbean islands may have increased risk of infectious or carrier state of hepatitis B virus (HBV); Native Americans, inner city, lower socioeconomic population, and immigrants from underdeveloped countries also have increased risk of tuberculosis.
Teaching/Learning
Risk factors include diabetes, malnutrition, drug/alcohol addiction, anemia.
DIAGNOSTIC STUDIES
Urinalysis/Serum, Culture and Sensitivity: Detects UTI, asymptomatic bacteremia, or GBS.
RPR or VDRL: Tests for syphilis.
Vaginal, Rectal, and Cervical Smears: Determines presence of gonorrhea, chlamydial infection, bacteria, GBS, or genital herpes.
Viral Titers: Identify presence of rubella and CMV.
Mantoux Skin Test with Purified Protein Derivative (PPD): Significant positive reaction suggests tuberculosis but does not distinguish between an active/dormant infection, or an infection caused by a different mycobacteria.
Hepatitis/HIV Screening: Done in presence of high-risk behaviors.
ELISA: Screens for HIV.
Western Blot test: Confirms HIV infection.
Complete Blood Count (CBC): Reveals anemia and indicators of infection (elevated WBC, differential shifted to the left).
Nucleic Acid Probe Test: Detects Mycobacterium tuberculosis.
Chest X-Ray: Visualizes nodular lesions, patchy infiltrates, cavitation, scar tissue, calcium deposits (tuberculosis).
Histology/Tissue Analysis, Needle Biopsy: To verify stage of tuberculosis.
Serial Ultrasonography: Detects IUGR.
Specimen of Vaginal Pool: Determines PROM.
NURSING PRIORITIES
1. Identify/screen for prenatal infection.
2. Provide information about protocol of care.
3. Promote client/fetal well-being.
DISCHARGE GOALS
1. Individual risks/conditions understood
2. Condition, prognosis, treatment needs understood
3. Participates effectively in therapeutic regimen
4. Pregnancy maintained as appropriate/desired
Activity/Rest
Malaise, fatigue
Generalized weakness
May report difficulty sleeping
Poor muscle tone/muscle wasting
Circulation
May be jaundiced
Elimination
Dysuria, urinary frequency, decreased urine output, hematuria
Food/Fluid
Nausea, vomiting, anorexia, weight loss.
Tongue may have visible lesion or sore (hairy leukoplakia seen in AIDS).
May report indigestion, altered taste.
Loss of subcutaneous fat.
Poor skin turgor.
Pain/Discomfort
Backache, flank pain, colicky pain noted with acute pyelonephritis.
Chest pain may occur with tuberculosis.
Severe itching, burning pain with lesions.
May complain of pruritus with active (infectious) hepatitis A or B.
Respiration
Dyspnea with exertion.
Cough may be productive of thick/purulent/blood-tinged sputum or may be nonproductive.
Crackles (rales), wheezes, bronchial breath sounds; tubular breath sounds, diminished/absent breath sounds over areas of pleural effusion or pneumothorax (tuberculosis).
Safety
Temperature elevation dependent on type of infection, e.g., low-grade in cystitis, high fever in pyelonephritis
Chills, night sweats
History of UTI
Positive cultures, elevated titers, positive screening for infectious disease
Exposure to body fluids or blood products through professional practice or through receiving a transfusion parenterally as a patient; carrier of group B beta-hemolytic streptococci (GBS) or of hepatitis B virus (HbsAg, anti-HBcAg)
Exposure to infectious agents through employment/environmental contact
Sexuality
May have history of early trimester pregnancy loss(es).
May currently have, or have previous exposure to, numerous heterosexual/bisexual partners, which increases risk for exposure to HIV and STDs; sexual partner may be hemophiliac, necessitating blood transfusions and placing him at risk for acquisition of HIV.
Vaginal discharge may be frothy, gray-green (trichomonal infection); whitish (candidal infection); thin, watery, yellow-gray, foul-smelling, “fishy” (Gardnerella vaginalis infection).
Strawberry patches on vaginal walls/cervix (trichomonal infection).
May have visible perineal or genital warts, lesions, or chancres.
Fundal height may not be AGA, possibly indicating IUGR associated with rubella or toxoplasmosis, or may correspond with gestational age of less than 37 wk, indicating increased risk for GBS.
Membranes may rupture prematurely (PROM).
Social Interaction
Immigrants from Africa or Haiti may have increased risk of AIDS; immigrants from Southeast Asia, Central America, or the Caribbean islands may have increased risk of infectious or carrier state of hepatitis B virus (HBV); Native Americans, inner city, lower socioeconomic population, and immigrants from underdeveloped countries also have increased risk of tuberculosis.
Teaching/Learning
Risk factors include diabetes, malnutrition, drug/alcohol addiction, anemia.
DIAGNOSTIC STUDIES
Urinalysis/Serum, Culture and Sensitivity: Detects UTI, asymptomatic bacteremia, or GBS.
RPR or VDRL: Tests for syphilis.
Vaginal, Rectal, and Cervical Smears: Determines presence of gonorrhea, chlamydial infection, bacteria, GBS, or genital herpes.
Viral Titers: Identify presence of rubella and CMV.
Mantoux Skin Test with Purified Protein Derivative (PPD): Significant positive reaction suggests tuberculosis but does not distinguish between an active/dormant infection, or an infection caused by a different mycobacteria.
Hepatitis/HIV Screening: Done in presence of high-risk behaviors.
ELISA: Screens for HIV.
Western Blot test: Confirms HIV infection.
Complete Blood Count (CBC): Reveals anemia and indicators of infection (elevated WBC, differential shifted to the left).
Nucleic Acid Probe Test: Detects Mycobacterium tuberculosis.
Chest X-Ray: Visualizes nodular lesions, patchy infiltrates, cavitation, scar tissue, calcium deposits (tuberculosis).
Histology/Tissue Analysis, Needle Biopsy: To verify stage of tuberculosis.
Serial Ultrasonography: Detects IUGR.
Specimen of Vaginal Pool: Determines PROM.
NURSING PRIORITIES
1. Identify/screen for prenatal infection.
2. Provide information about protocol of care.
3. Promote client/fetal well-being.
DISCHARGE GOALS
1. Individual risks/conditions understood
2. Condition, prognosis, treatment needs understood
3. Participates effectively in therapeutic regimen
4. Pregnancy maintained as appropriate/desired
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