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WEIGHT AND HEIGHTWEIGHT AND HEIGHT
MEASUREMENTMEASUREMENT
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WEIGHING AN INDIVIDUALWEIGHING AN INDIVIDUAL
DEFINITION
:
A process whereby the individual is place over the weighing scaleto determine the weight.
Equipments:
Balanced weighing scale, paper towel
DEFINITION
:
A process whereby the individual is place over the weighing scaleto determine the weight.
Equipments:
Balanced weighing scale, paper towel
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Objective:Objective:
1. For diagnostic aid or as an aid in the
assessment of therapeutic effectiveness.
2. Provide a basis for future evaluation.
3. To determine patient's weight and
progress.
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MEASURING WEIGHTMEASURING WEIGHT
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Procedure: Rationale
1. Prepare the patient to be weighed - to get the consent ofthe patient
2. Place a paper towel on the scale -for aseptic purposes
3. Remove slippers/ shoes or heavy -to determine the
objects/accessories found in the accuracy in the patients
pocket weight.
4. Instruct patient to mount over the flat -unnecessary movement
form of the weighing scale, stand and improper posture
erect and avoid unnecessary move- will result to inaccuracy
ments. In reading the scale.
5. Get the reading. - to determine the actual
weight of the patient.
6. Record the reading -data for evaluation.
Procedure: Rationale
1. Prepare the patient to be weighed - to get the consent ofthe patient
2. Place a paper towel on the scale -for aseptic purposes
3. Remove slippers/ shoes or heavy -to determine the
objects/accessories found in the accuracy in the patients
pocket weight.
4. Instruct patient to mount over the flat -unnecessary movement
form of the weighing scale, stand and improper posture
erect and avoid unnecessary move- will result to inaccuracy
ments. In reading the scale.
5. Get the reading. - to determine the actual
weight of the patient.
6. Record the reading -data for evaluation.
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MEASURING HEIGHTMEASURING HEIGHT
Measuring tape should be cut at bottom
so that 0 measure is at the floor.
Measuring tape should be cut at seven
feet on top.
Place the tape straight up and down
securely on the wall or door.
Measuring tape should be cut at bottom
so that 0 measure is at the floor.
Measuring tape should be cut at seven
feet on top.
Place the tape straight up and down
securely on the wall or door.
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Procedure:
1. Have patient remove shoes, heavy outer clothing, hats,and barrettes.
2. Have patient undo a hairstyle that interferes withmeasurements. If the patient is unwilling or unable toundo hairstyle, locate crown of the head to the best ofyour ability.
3. Have patient stand with his/her back and feet against thewall on a flat floor directly in front of the measuring tape.You may wish to mark the floor with masking tape to
indicate where the patient should stand. The tape shouldrun directly down the center of his/her back.
4. Patient should stand with the back as straight as possible.Weight should be evenly distributed on both feet.
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Position the patient withheels close together, legsstraight, arms at sides, andshoulders relaxed.Buttocks and shouldersshould touch the wall.
Have patient inhale deeplyand stand fully erectwithout altering heelposition or allowing heels
to rise off the floor.
Have patient look straightahead with head erect.
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Place the square flat againstthe wall. Lower it until it
firmly touches the crown ofthe head with sufficientpressure to compress thehair.
Hold the square steady andhave the patient move outfrom under the square.
Read the measurement at eyelevel where the lower edge ofthe square intersects themeasuring tape.
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Charting:
Accurate recording of weight is
Essential.
Patient Name Date/Time
Remarks
Nicole 01/22/09 110LBS9:00 AM
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Estimating Gestational AgeEstimating Gestational AgeIf everyone had normal, regular
periods, every 28 days, and could
remember exactly when their last periodwas, and ovulation always occurred onday #14 of the menstrual cycle, thengestational age determination would beeasy. These assumptions, however, arenot always the case. In real life,determining gestational age can bechallenging.
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Naegeles
Rule
Naegeles
Rule
An alternative method of
determining the due date is to add 7days to the LMP, subtract three
months, and add one year. These
calculations are made easier with the
use of a pregnancy wheel or
Gestational Age Calculator.
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For example:
If a women says her last normal menstrual
period occurred May 7, 2008 her EDD or
EDC would be February 14, 2009.
May 7 2008
- 3 months + 7days + 1 year
= February =14, = 2009
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MacDona
ld'sRu
le.Ma
cDona
ld'sRu
le.One way to approximate a pregnancy's
current gestational age is to use a tape
measure to determine the distance fromthe pubic bone up over the top of theuterus to the very top. That distance,measured in centimeters, is approximatelyequal to the weeks of gestation, from
about mid-pregnancy until nearly the endof pregnancy. This is known asMacDonald's Rule.
One way to approximate a pregnancy'scurrent gestational age is to use a tape
measure to determine the distance fromthe pubic bone up over the top of theuterus to the very top. That distance,measured in centimeters, is approximatelyequal to the weeks of gestation, from
about mid-pregnancy until nearly the endof pregnancy. This is known asMacDonald's Rule.
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If a tape measure is
unavailable, these rough
guidelines can be used:
At 12 weeks, the uterus isjust barely palpable
above the pubic bone,
using only an abdominal
hand.
At 16 weeks, the top of the
uterus is 1/2 way
between the pubic bone
and the umbilicus.
At 20-22 weeks, the top of
the uterus is right at the
umbilicus.At full term, the top of the
uterus is at the level of
the ribs. (xyphoid
process).
If a tape measure is
unavailable, these rough
guidelines can be used:
At 12 weeks, the uterus isjust barely palpable
above the pubic bone,
using only an abdominal
hand.
At 16 weeks, the top of the
uterus is 1/2 way
between the pubic bone
and the umbilicus.
At 20-22 weeks, the top of
the uterus is right at the
umbilicus.At full term, the top of the
uterus is at the level of
the ribs. (xyphoid
process).
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Fund
al
heig
ht
Fund
al
heig
ht
Distancein CentimeterX 8
-----------------------------
7
= total weeks ofgestation
Ex: 20cm X 8/7 = 22 weeks
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GRAVIDA and
PARAGRAVIDA and
PARA
Gravida is the number of times thewoman has been pregnant
Para is the number of infantsdelivered after 20 weeks gestation,
born dead or alive; multiple birthscount as one delivery regardless ofthe number of infants delivered.
Gravida is the number of times thewoman has been pregnant
Para is the number of infantsdelivered after 20 weeks gestation,
born dead or alive; multiple birthscount as one delivery regardless ofthe number of infants delivered.
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TPALis
m
ore
descripti
on of ParaTPAL
ism
ore
descripti
on of ParaTPAL
ism
ore
descripti
on of ParaTPAL
ism
ore
descripti
on of Para
T is the number of infants born after 37
weeks.
P is the number of infants born between 20and 37 weeks.
A- is the number of pregnancies that end in
spontaneous or therapeutic abortion prior
to 20 weeks.
L- is the number of children currently alive.
T is the number of infants born after 37
weeks.
P is the number of infants born between 20and 37 weeks.
A- is the number of pregnancies that end in
spontaneous or therapeutic abortion prior
to 20 weeks.
L- is the number of children currently alive.
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For Example :
Mrs. Marie reports that she has a 3
years old child at home who was
born at term, had a miscarriage at10 weeks gestation, and delivered a
set of twins at 37weeks gestation
that dies within 24hrs. In the
prenatal Record, the nurse should
record:
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Answer!
Answer!
GRAVIDA- 3
PARA- 2
T- 3
P- 2
A- 1
L- 1
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THANK YOUTHANK YOU
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Biophysical Profile
A biophysical profile (BPP) testmeasures the health of yourbaby (fetus) during pregnancy. ABPP test may include anonstress test with electronicfetal heart monitoring and afetal ultrasound.
Components:
1
. Fetal movement 2. Fetal tone
3. Fetal breathing
4. Amniotic fluid volume
5. Fetal Heart Rate
Normal variables areassigned a score of 2 each.
A score of 8-10 means
Normal; 6 meansequivocal; & 4 or less
means abnormal.
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Nonstress test
Assess FHRacceleration inresponse to fetalactivity in fetus inhealthy condition
Maternal indications:post maturity, Rhsensitization, > 35years old, chronicrenal problem, sickle
cell, collagen disease,DM, PROM, trauma,bleeding during 2nd &3rd trimester.
Result Interpretation Significance
Reactive 2 or more
acceleration of 15
beats/min lasting 15
sec or more in 20 min
period.
High- risk
pregnancy
allowed to
continue if twice
weekly NSTs arereactive.
Non Reactive No FHR acceleration
or less than 15 beats/
min or lasting less
than 15 sec thru fetalmovement.
Need to attempt
to clarify FHR
pattern;
implement CST &continue external
monitoring
Unsatisfactory FHR pattern not able
to be interpreted.
Repeat NST or do
CST
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Contraction stress test
A test used to establish thefetal ability to withstandstress of contraction when
labor comes.
Usually performed if womenhas a nonreactive NST orequivocal VST.
Contraindications: 3rd
trimester bleeding, previousclassical CS, hx of pretermlabor, PROM, hydramios,incompetent cervix, placentaprevia.
Result Interpretation Significance
Negative 3 contractions, 40-
60 sec long, within10 min period, no
late deceleration
Fetus should
tolerate labor if itoccurs within 1
week.
Positive Persistent/
consistent late
decelerations with
more than contractions
Fetus at
increased risk.
May need
additionaltesting, may try
induction orCesarean birth
Suspicious Late decelerations
in less than contraction
Repeat CST in 24
hrs., or otherfetal assessment
tests.
Unsatisfactory Inadequate pattern
or poor tracing
Same as for
suspicions
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FETAL CIRCULATION