NM610 Primary Care of Women

NM610 Primary Care of Women

Clinical Objectives

CLINICAL OBJECTIVES

I. KNOWLEDGE

A..Systematically compiles & updates a complete & relevant database for the comprehensive assessment of each client’s health, incl. a thorough health hx & physical exam.

1.Incorporates basic principles of interpersonal relationships into interviewing and history-taking

a.Introduces self

b.Accepts and values client diversity

c.Tells patient what to expect

e.Sees to patient's comfort

f.Cares for immediate concerns

g.Shows interest in patient as an individual

h.Avoids expression of inappropriate value judgments

i.Uses eye-contact; demonstrates interest/listening

j.Identifies/explores "clues" & significant comments

k.Recognizes, evaluates, and responds appropriately to patient's nonverbal behavior

2.Uses appropriate interviewing techniques

(1)Starts with present circumstance

(2)Asks specific questions clearly and succinctly

(3)Uses appropriate vocabulary

(4)Explains new terms

(5)Uses open-ended questions & responses

(6)Pauses to allow for expression

(7)Allows sufficient time to answer questions

(8)Controls & keeps interview moving

(9)Obtains complete data in a logical, orderly manner

(10)Teaches appropriately (timing & information)

(11)Terminates interview appropriately

3.Elicits a complete gynecological history, including:

(1)Biographical (identifying) data

(2)Personal/social (lifestyle, environmental) data

(3)Chief complaint

(4)Present obstetrical (health/illness) data

(5)Past obstetrical/gynecological data

(6)Past health (medical/surgical) data

(7)Review of systems

(8)Family health data

4.Performs a systematic, accurate, complete, and gentle physical

examination on women in the childbearing years and screens for gross deviations and abnormalities.

a.Initiates physical assessment by observing general appearance for:

(1)Level of wellness/apparent state of health

(2)State of awareness/affect

(3)Signs of distress

b.Examines the heart and respiratory system

c.Examines the breasts and axilla

(1)Prepares and informs client appropriately for breast examination

(2)Inspects the breasts with the client in each of four positions for symmetry, elevation, and dimpling (retraction):

-with arms at sides

-with arms raised above head

-with hands on waist and squeezing

-with arms extending forward, chin up and bending forward at the waist as indicated

(3)Inspects axilla and supraclavicular region for color, smoothness, and contour

(4)Palpates axilla and supraclavicular region to rule out enlarged lymph nodes while client is sitting or after palpating breast

(5)Palpates breast, gently but firmly, with part of fingers systematically while client is in the supine position with arm raised above her head

(6)Describes any mass found in terms of location, size, shape, consistency, outline, mobility, and tenderness

(7)Palpates nipple noting any discharge/deviation

(8)Determines client's knowledge of/readiness to learn Self-Breast Examination

(9)Teaches Self-Breast examination to client and obtains return demonstration from client as appropriate.

d.Examines the abdomen

(1)Assists client to relax abdominal wall

(2)Monitors examination by watching client's face for sign of discomfort

(3)Inspects abdomen for contour, symmetry, condition of skin and umbilicus, peristalsis, and pulsations

(4)Auscultates abdomen for normal bowel sounds as indicated

(5)Percusses abdomen for tympany versus dullness in four quadrants/nine sections as indicated

(6)Percusses right upper quadrant to outline lower edge of liver as indicated

(7)Lightly palpates abdomen noting and inguinal lymph nodes noting resistance/tenderness

(8) Deeply palpates abdomen

-Palpates lower edge of liver

-Palpates left upper quadrant for spleen

(9)Describes any masses found in terms of size, shape, location, consistency, mobility, and tenderness

(10)Measures fundal height on a pregnant women

(11)Systematically performs four steps of Leopold's maneuvers on pregnant abdomen

e.Examines the back and the extremities

(1)Notes client's movements and posture throughout the interview and examination

(2)Inspects for symmetry of shoulders, hips, scapula

(3)Observes spine noting the cervical, thoracic, and lumbar curves, and lateral curves if present

(4)Palpates spinous processes and paravertebral muscles to rule out tenderness

(5)Palpates costovertebral angle area to rule out tenderness

(6)Inspects extremities for:

-edema

-varicosities

-equal size and shape of muscle mass

-normal range of motion

f.Examines the female reproductive system

(1)Prepares room and assembles equipment

(2)Prepares client by explaining/clarifying procedures and positioning comfortably

(3)Inspects and palpates the external genitalia

-Examines by gently "milking" the Skene's glands and urethra looking for exudate

-Palpates for enlargement of Bartholin glands

(4)Inspects the vagina and cervix using a speculum

-Inserts speculum correctly and visualizes vagina and cervix

-Obtains Pap Smear and/or G.C. culture, chlamydia culture or wet prep as indicated

-Removes speculum correctly

(5)Examines the pelvic area bimanually

-Identifies the cervix and notes its size, shape, consistency, and mobility

-Palpates the uterus and adnexa noting location, position, size, shape, consistency, and mobility

-Locates and palpates the following landmarks of the bony pelvis: sacrospinous ligament, sacrum, coccyx subpubic arch, retropubic angle, sidewalls, ischial, ischial spines, tuberosities

(6)Examines the rectum to evaluate sphincter tone, and explore for masses, lesions, nodes, external and internal hemorrhoids, fissures, fistulas, anorectal polyps or tumors

g. Examines the extremities

5.Records examination findings completely, accurately, concisely, legibly, and in appropriate terminology

6.Accurately obtains or orders laboratory data as needed.

B.Identifies problems/situations and formulates diagnoses based upon interpretation of the database.

1.Organizes data for preliminary diagnosis:

a.clusters data appropriately

b.identifies tentative diagnosis

c.identifies missing information

d.obtains additional data as necessary (includes history, physical, laboratory and other data)

2.Verifies diagnoses with appropriate faculty member.

C.Identifies health care needs/problems in collaboration with the client: Provides information & support to enable clients to make informed decisions and to assume primary responsibility for their own health.

1.Promotes mutual goal-setting between patient and self; between instructor and self

a.Identifies own goals in situation

b.Elicits goals of other(s) in situation

c.Discusses points of agreement/conflict

d.Arrives at mutually acceptable compromise of conflict

2. Provides clear and accurate anticipatory guidance and counseling regarding:

a.general health promotion and wellness (primary, reproductive and breast health)

b. primary health maintenance or problems/conditions within all systems

c.contraception, family planning

d.gynecological deviations from normal

1.breast findings

2.pap findings

3.pelvic findings

e.laboratory findings for all body systems

D.Develops a comprehensive plan of care with the client

1.Identifies possible treatment plans and consequences of each.

2.Provides description of diagnosis, finalizing the plan of management of potential problems and rationale for plan.

3.Informs consumer of options, rationale, risks, sequelae, and limitations of therapeutic milieu including anticipated procedures (prior to institution of procedures)

4.Identifies need for appropriate additional lab tests.

5.Plans for subsequent assessment at appropriate intervals.

6.Utilizes appropriate faculty consultation for validation of management plan.

7.Selects most appropriate therapeutic plan based on valid rationale.

8.Verifies plan of care with appropriate faculty member.

E.Assumes primary responsibility for the implementation of individualized plans.

1.Orders appropriate additional lab tests.

2.Orders appropriate treatment(s).

3.Performs appropriate procedures.

4.Arranges for subsequent assessments at appropriate intervals.

5.Obtains appropriate medical consultation or collaboration.

6.Records data legibly, concisely, and logically.

7.Facilitates entry into and utilization of health care system.

8.Verifies implementation with appropriate faculty member

F.Obtaining consultation, planning, and implementing collaborative management; referral or transferring the care of the client as appropriate

G.Initiates management of specific complications, emergencies and deviations from normal.

1.Verifies management with appropriate faculty member

H.Evaluates, with the client, the effectiveness of care and modifying the plan of care as appropriate.

1.Predicts expected outcomes of management plan.

2.Identifies methods for follow-up evaluation.

3.Provides for follow-up evaluation when possible.

4.Identifies implications of treatment results for subsequent practice

5.Verifies evaluation with appropriate faculty member.

II. SKILLS

A.Performs all skills in a manner which:

1.Demonstrates correct and efficient use of hands, instruments, and equipment

2.Results in obtaining accurate data or in the safe completion of an appropriate

procedure/maneuver

3.Causes the least possible physical and/or psychological discomfort to the

consumer

4.Demonstrates consistency

III.VALUES

Incorporates appropriate values in the assessment process.

Values diversity.

Respects and integrates client’s values.

Incorporates appropriate values in the assessment process.

• Values diversity.
• Respects and integrates client’s values.

Incorporates appropriate values in the assessment process

Values diversity

Respects and integrates client’s values

Demonstrates actions, interactions and attitudes consistent with ACNM Standards of Practice (2003), Core Competencies for Basic Midwifery Practice (2002) and Code of Ethics (Revised, 2004).

Demonstrates actions, interactions and attitudes that positively facilitate intra and interdisciplinary collegiality.

Demonstrates actions, interactions and attitudes that facilitate achievement of the following Hallmarks of Midwifery (2002):

Recognition of pregnancy, birth, and menopause as normal physiologic and developmental processes

Advocacy of non-intervention in the absence of complications

Incorporation of scientific evidence into clinical practice

Promotion of family-centered care

Empowerment of women as partners in health care

Facilitation of healthy family and interpersonal relationships

Promotion of continuity of care

Health promotion, disease prevention, and health education

Promotion of a public health care perspective

Care to vulnerable populations

IV.MEANINGS AND EXPERIENCES

A.Individual Qualities

1.Takes responsibility for own learning.

2.Achieves appropriate theory grasp.

3.Accepts responsibility for decision-making and consequences.

4.Demonstrates integrity and reliability.

5.Develops an environment of mutual respect in any professional

interaction.

6.Demonstrates ability to cope with stressful or emotional situations in a

constructive manner.

7.Knows own limitations; protects the safety of the client.

B.Communication

1.Exchanges information in manner which consumer understands and provides an opportunity for asking questions (interaction).

2.Communicates appropriately with health care team members, faculty and

peers.

3.Promotes family centered care and provides opportunity for consumer to receive support from significant other.

4.Maintains and respects privacy.

5.Promotes consumer's rights to make and be responsible for decision

concerning personal health care.

6.Demonstrates sensitivity to the biases/constraints of the consumer.

C.Approach to Health Care System

1.Identifies bioethical considerations related to reproductive health.

2.Uses appropriate community resources.

3.Advocates principles of health promotion and disease prevention.

4.Promotes pregnancy as a normal physiologic process.

5.Demonstrates awareness of cost/benefits ratio in health care.

• Advocacy for informed choice, shared decision-making, and the right to self-determination
• Cultural competence
• Familiarity with common complementary and alternative therapies
• Skillful communication, guidance, and counseling
• Therapeutic value of human presence
• Collaboration with other members of the health care team.

IV.MEANINGS:

1.Apply meanings to client’s health which have been derived from this exam.

a.Individual Qualities

1.Takes responsibility for own learning

2.Achieves appropriate understanding of theory

3.Accepts responsibility for decision-making and consequences thereof

4.Demonstrates integrity and reliability

5.Develops an environment of mutual respect in any professional interaction

6.Demonstrates ability to cope with stressful or emotional situations in a constructive manner

7.Knows own limitations; protects the safety of the client

b.Communication

1.Exchanges information in manner which consumer understands and provides an opportunity for asking questions

2.Communicates appropriately with health care team members, faculty and peers.

3.Promotes family centered care and provides opportunity for consumer to receive support from significant other

4.Maintains and respects privacy

5.Promotes consumer's rights to make and be responsible for decisions concerning personal health care

6.Demonstrates sensitivity to the biases/constraints of the consumer

c.Approach to Health Care System

1.Uses appropriate community resources

2Advocates principles of health promotion and disease prevention

3.Promotes pregnancy as a normal physiologic process.

4.Demonstrates awareness of cost/benefits ratio in health care.

Revised 2008

ACNM Standards for the Practice of Midwifery, 2003, and

ACNM Code of Ethics, Revised 2004