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DEFINITION : A process whereby the individual is place over the weighing scale to determine the weight.

Equipments: Balanced weighing scale, paper towel


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.


1. 2. 3.

- to get the consent of the patient -for aseptic purposes -to determine the accuracy in the patients weight. -unnecessary movement and improper posture will result to inaccuracy In reading the scale. - to determine the actual weight of the patient. -data for evaluation.

Prepare the patient to be weighed Place a paper towel on the scale Remove slippers/ shoes or heavy objects/accessories found in the pocket Instruct patient to mount over the flat form of the weighing scale, stand erect and avoid unnecessary movements. Get the reading. Record the reading


5. 6.

 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.


Have patient remove shoes, heavy outer clothing, hats, and barrettes. Have patient undo a hairstyle that interferes with measurements. If the patient is unwilling or unable to undo hairstyle, locate crown of the head to the best of your ability. Have patient stand with his/her back and feet against the wall 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 should run directly down the center of his/her back. Patient should stand with the back as straight as possible. Weight should be evenly distributed on both feet.




Position the patient with heels close together, legs straight, arms at sides, and shoulders relaxed. Buttocks and shoulders should touch the wall. Have patient inhale deeply and stand fully erect without altering heel position or allowing heels to rise off the floor. Have patient look straight ahead with head erect.

Place the square flat against the wall. Lower it until it firmly touches the crown of the head with sufficient pressure to compress the hair. Hold the square steady and have the patient move out from under the square. Read the measurement at eye level where the lower edge of the square intersects the measuring tape.

Charting: Accurate recording of weight is Essential. Patient Name Remarks Nicole Date/Time 01/22/09 9:00 AM 110LBS

Estimating Gestational Age

If everyone had normal, regular periods, every 28 days, and could remember exactly when their last period was, and ovulation always occurred on day #14 of the menstrual cycle, then gestational age determination would be easy. These assumptions, however, are not always the case. In real life, determining gestational age can be challenging.

Naegeles Rule
An alternative method of determining the due date is to add 7 days 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.

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 3 months + 7days = February =14, 2008 + 1 year = 2009

MacDonald's Rule.
One way to approximate a pregnancy's current gestational age is to use a tape measure to determine the distance from the pubic bone up over the top of the uterus to the very top. That distance, measured in centimeters, is approximately equal to the weeks of gestation, from about mid-pregnancy until nearly the end of pregnancy. This is known as MacDonald's Rule.

If a tape measure is unavailable, these rough guidelines can be used: At 12 weeks, the uterus is just 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).

Fundal height
Distance in Centimeter X 8 ----------------------------7 = total weeks of gestation Ex: 20cm X 8/7 = 22 weeks


Gravida is the number of times the woman has been pregnant Para is the number of infants delivered after 20 weeks gestation, born dead or alive; multiple births count as one delivery regardless of the number of infants delivered.

TPAL is more description of Para

T is the number of infants born after 37 weeks. P is the number of infants born between 20 and 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.

For Example : Mrs. Marie reports that she has a 3 years old child at home who was born at term, had a miscarriage at 10 weeks gestation, and delivered a set of twins at 37weeks gestation that dies within 24hrs. In the prenatal Record, the nurse should record:


GRAVIDA- 3 PARA- 2 T- 3 P- 2 A- 1 L- 1


Biophysical Profile
 A biophysical profile (BPP) test

measures the health of your baby (fetus) during pregnancy. A BPP test may include a nonstress test with electronic fetal heart monitoring and a fetal ultrasound.

 Normal variables are assigned a score of 2 each.  A score of 8-10 means Normal; 6 means equivocal; & 4 or less means abnormal.

Components:  1. Fetal movement  2. Fetal tone  3. Fetal breathing  4. Amniotic fluid volume  5. Fetal Heart Rate

Nonstress test
 Assess FHR acceleration in response to fetal activity in fetus in healthy condition  Maternal indications: post maturity, Rh sensitization, > 35 years old, chronic renal problem, sickle cell, collagen disease, DM, PROM, trauma, bleeding during 2nd & 3rd trimester.


High- risk pregnancy allowed to continue if twice weekly NSTs are reactive. Need to attempt to clarify FHR pattern; implement CST & continue external monitoring Repeat NST or do CST


2 or more acceleration of 15 beats/min lasting 15 sec or more in 20 min period. No FHR acceleration or less than 15 beats/ min or lasting less than 15 sec thru fetal movement. FHR pattern not able to be interpreted.

Non Reactive


Contraction stress test





3 contractions, 4060 sec long, within 10 min period, no late deceleration Persistent/ consistent late decelerations with more than contractions

Fetus should tolerate labor if it occurs within 1 week. Fetus at increased risk. May need additional testing, may try induction or Cesarean birth

 A test used to establish the

fetal ability to withstand stress of contraction when labor comes.

 Usually performed if women


has a nonreactive NST or equivocal VST.

 Contraindications: 3rd

trimester bleeding, previous classical CS, hx of preterm labor, PROM, hydramios, incompetent cervix, placenta previa.

Late decelerations in less than contraction

Repeat CST in 24 hrs., or other fetal assessment tests. Same as for suspicions


Inadequate pattern or poor tracing