In the postpartum period, secondary postpartum hemorrhage (SPPH) and endometritis are two conditions that frequently present to an obstetric triage unit. These complications may coexist and can occur from 24 hours postpartum to 6 weeks postdelivery. SPPH is typically not as severe as a primary bleeding episode. Postpartum women ultimately diagnosed with endometritis are generally stable, but less commonly can present in septic shock. This chapter discusses presenting symptomatology, history and data collection, physical examination, laboratory and imaging studies, differential diagnosis, and clinical management and follow-up of secondary postpartum hemorrhage and postpartum endometritis. Prompt treatment of both SPPH and postpartum endometritis can reduce maternal morbidity and mortality. SPPH is managed with the same guiding principles as primary postpartum hemorrhage. Initial treatment for postpartum endometritis is intravenous clindamycin and gentamicin.
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Intimate partner violence (IPV) and sexual assault are common violent crimes perpetrated on women. Obstetric (OB) complications associated with trauma include miscarriage, preterm labor, and placental abruption. Ongoing mental health issues, including depression and anxiety, are more prevalent in pregnant women subjected to any form of IPV, whether or not direct physical violence is involved. One study showed that pregnant women subjected to verbal threats were twice as likely to deliver low-birth-weight infants. All women who present to an OB triage unit or an emergency department (not just those who present with an injury or complication) must be screened for IPV. An organized plan for providing the victim with resources must be readily available when a screen is positive. This chapter discusses presenting symptomatology, history and data collection, physical examination, laboratory and imaging studies, differential diagnosis, clinical management and follow-up care of IPV and sexual assault.
The physical assessment of the pediatric obese patient is similar, yet different, to that of an adult obese patient. It is important to include family in the interview and assessment, as the goal needs to be a collaborative effort for evaluation, assessment, and treatment. Similar to an adult assessment, key skills, including critical thinking, scientific knowledge bases, experience, clinical competencies, attitude, and standard of care, need to be utilized. The health history should be taken directly from the patient and a family member. It is important to use any previous medical records for a complete review. A physical examination should start with the head and progress downward to the toe. Variations in the obese pediatric patient’s physical examination can be seen in multiple areas. Pediatric variations also need to be considered in physical examination. Differential diagnoses should be considered with pediatric obesity. This includes hypothyroidism, Down syndrome, or Prader-Willi syndrome.
Critical thinking is required in performing an accurate physical assessment. Critical thinking encompasses analysis of data using the scientific knowledge base, experience, clinical competencies, attitude, and standard of care. These specific areas allow the advanced practice nurse (APN) to hone in on the health assessment and physical examination. Prior to the physical examination, a thorough health history needs to be taken. The health history or history of present illness (HPI) provides the patient’s reason for seeking out the APN and documents the chronological signs and symptoms of the problem from beginning to end. The APN should complete a head-to-toe physical assessment and review vitals and measurements. A complete physical examination for the obese patient should be similar to a normal physical examination with some slight variations. A head-to-toe physical examination includes four basic skills: inspection, palpation, percussion, and auscultation.
The evaluation of pain in the cancer setting is one of the most important and challenging tasks faced by the rehabilitation clinician. This chapter intends to provide a concise conceptual framework for the evaluation of pain. Failure to accurately and specifically determine the cause of pain will lead the clinician to pursue treatment strategies that may be ineffective, inappropriate, and potentially dangerous. Pain in the cancer population is divided into that which is (a) caused by disease, (b) caused by treatment, and (c) unrelated to disease or treatment. An accurate diagnosis of pain begins with a thorough history; the clinician should strive to fully understand all components of the patient’s cancer diagnosis. Physical examination is often the most important diagnostic modality the clinician has in arriving at a correct diagnosis it includes inspection, palpation, range of motion (ROM) assessment, neurologic assessment, and special tests.
Basic assessment skills of observation, interview, and examination can aid in differentiating normal from abnormal findings and identifying changes. In addition to using these skills when completing the Minimum Data Set (MDS), nurses can incorporate them into general nursing activities so that every nurse–resident interaction provides an opportunity for assessment. This chapter describes the basic skills used in assessment and outlines the components and skills used in conducting a comprehensive physical assessment. Physical examination utilizes several major skills, such as: inspection, auscultation, percussion, and palpation. The chapter also explains the method of conducting a mental status assessment. Mental status is examined by: observations of general attention to grooming, appropriateness of dress, body language, and general behavior, language and speech, affect, responses to questions, and the use of standardized assessment tools.
Polycystic ovarian syndrome (PCOS) is an endocrine disorder and one of the most commonly occurring endocrine disorders in women. PCOS is the most common cause of female subfertility. This chapter describes Rotterdam criteria for classification of PCOS. It then provides clinical screening for PCOS. The screening process includes physical examination such as hair distribution; breast examination; peripheral exam; laboratory analysis such as free testosterone; estradiol; serum prolactin; clinical intervention such as patient education; pharmacotherapy and pregnancy-related risks. The chapter describes the goals for management of PCOS. The goals are to lower insulin levels; restore/preserve fertility; treat hirsutism and/or acne; regulate menstruation; prevent endometrial hyperplasia and hence prevent development of endometrial cancer. The decision is driven by whether the woman is younger or older, as well as her desire for future conception.