Assessment

Introduction to the Nursing Process and Assessment

The nursing process is a systematic, five-step framework that guides midwives in delivering holistic, individualized care to mothers and newborns. These steps include assessment, diagnosis, planning, implementation, and evaluation.

Assessment is the critical first phase. Without a thorough and accurate assessment, subsequent care plans will fail to address the actual needs of the woman. In Nigerian midwifery practice, a proper assessment uncovers not just physical ailments, but also social, cultural, and economic factors that influence a pregnancy outcome. It is an ongoing activity that begins the moment a pregnant woman walks into the clinic and continues through labor, delivery, and the postnatal period.

Differentiating Objective and Subjective Data

Gathered information falls into two distinct categories during a clinical evaluation.

• Subjective data: These are symptoms and feelings reported directly by the patient or her relatives. Examples include nausea, headache, anxiety, and the history of lower abdominal pain. Midwives capture these using active listening during history-taking.
• Objective data: These are measurable, observable signs discovered by the midwife through physical examination, laboratory results, and diagnostic tools. Examples include blood pressure readings, fetal heart rate, temperature, and protein in the urine via dipstick.

Both data types are necessary to paint a complete picture of the mother's health status.

Methods of Data Collection: Interview and Physical Examination

Midwives rely on specific methods to gather comprehensive health information.

1. The Interview: This is a purposeful conversation with the patient. It requires good communication skills, empathy, and cultural sensitivity. In Nigeria, building rapport before asking sensitive questions about obstetric history or family planning is vital.
2. Physical Examination: This follows a systematic head-to-toe approach or a focused obstetric examination. It utilizes four main techniques: inspection (looking), palpation (feeling), percussion (tapping), and auscultation (listening, such as using a Fetoscope to hear the fetal heart).

Combining these methods ensures that subtle warning signs of complications are not missed.

Validating Findings

Validation is the process of confirming that the data collected is complete and accurate. A midwife cannot act on assumptions. If a primigravida presents with a blood pressure of 150/96 mmHg, a prudent midwife validates this finding by allowing the patient to rest briefly and repeating the measurement, checking the correct cuff size, and assessing for other signs of pre-eclampsia like visual disturbances or severe headache. Validation prevents errors in clinical judgment and ensures that interventions match the true clinical reality.

Documenting Findings

Documentation is the legal and professional record of the assessment phase. In Nigerian healthcare facilities, records may be paper-based or electronic, but the rules remain the same: if an assessment finding is not documented, legally, it was never done.

Good documentation must be factual, prompt, and descriptive. Avoid vague terms like "patient is doing well." Instead, write precise observations such as "Contractions occurring every 4 minutes lasting 45 seconds; moderate intensity." Proper documentation ensures safe continuity of care when handing over to the next shift of midwives.