Leopolds-Maneuvers-Fundic-Height-Measurement-and-FHT-Determination-Checklist-3 PDF

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Summary

PERFORMING FUNDIC HEIGHT MEASUREMENT, LEOPOLD’S MANEUVERAND DETERMINATION OF THE POINTS OF MAXIMAL INTENSITY FOR FHT( FETAL HEART TONE )Purpose: 1. To estimate fetal size and height of the fundus 2. To systematically observe and palpate the abdomen to determine fetal presentation and position. To de...

Description

PERFORMING FUNDIC HEIGHT MEASUREMENT, LEOPOLD’S MANEUVER AND DETERMINATION OF THE POINTS OF MAXIMAL INTENSITY FOR FHT ( FETAL HEART TONE ) Purpose: 1. To estimate fetal size and 3. To determine the number of height of the fundus fetus in the uterine cavity. 2. To systematically observe and 4. To determine the landmark for palpate the abdomen to fetal heart tone. determine fetal presentation and position. Materials/ Equipment needed/ required: 1. Examining table with bed sheet cover, pillow with pillow case. 2. Bed sheet to cover the client Assessment: 1. Assess Client’s age of gestation ( AOG) 2. Assess for general appearance of the abdomen and abdominal scar’s 3. Assess client general appearance and condition 4. Assess the urinary bladder area for distention.

3. 4. 5. 6.

Tape measure Stethoscope Wristwatch with second hand Screen

Nursing Diagnoses: 1. Anxiety related to findings of fetal presentation and position 2. Potential for injury to mother and fetus related to manipulation during the maneuver. Outcome Identification and Planning: 1. Washes hands 2. Prepares materials needed. 3. Ask client to empty bladder if able; if unable serve a bed pan. Expected Outcome: 1. Client will verbalize acceptance on the present condition gradually 2. Client will report no untoward signs of injury. DETERMINATION OF PMI OF FHT Wash hands . Perform Leopold maneuvers. Auscultate fetal heart tones (FHTs)based on fetal presentation identified with Leopold maneuvers. The PMI is the location where the FHTs are heard the loudest, usually over the fetal . Chart PMI of FHTs using a two-line figure indicate the four quadrants of he maternal abdomen , as follows; right upper quadrant (RUQ) left upper quadrant (LUQ), left lower quadrant (LLQ) and right lower quadrant (RLQ).

The umbilicus is the reference point for the quadrants ( point where the lines cross). The PMI for the fetus in vertex presentation in general flexion with the back on the mother’s right side , commonly is found in the mother’s right lower quadrant and is recorded with an “ X “ or with the FHT, as follows

X

RUQ

LUQ

RLQ

LLQ

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FUNDIC HEIGHT MEASUREMENT IMPLEMENTATION Nursing Action Assessment 1. Assess the client AOG

Rationale  To determine month/ weeks of gestation (7 mos. Or 28 weeks.) Previous surgery can leave 2. Assess general appearance of the  abdomen and condition of the client. adhesion.  An overall impression of the child’s mother health and well-being can provide information and guidance on ways to alleviate discomforts of pregnancy. Planning 3. Washes hands 4. Prepares materials needed 5. Explains procedure to the client.  Reduces anxiety and ensures cooperation of client. 6. Asks client to empty bladder.

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A distended bladder would interfere with the findings and would increase maternal discomfort during examination Prevents the spread of microorganism. Avoids embarrassment

7. Washes hands before starting

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8. Provides privacy by using screen/ closing the door.

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9. Asks client to lie flat on back ( supine/dorsal recumbent position)

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Relive tension on the abdominal muscles and for clients comfort.

10. Covers client with bed sheet, expose the area to be examined, by folding down to the symphysis pubis the bed sheet, lower down to symphysis pubis the underwear and folder up to the xiphoid process the clothes. 11. Rubs both hands together or submerge hands in warm water before touching the client. 12. The top of the fundus is palpated and a tape measure in centimeters is stretched from the top of the symphysis pubis over the abdominal curve to the top of the fundus.

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Ensures privacy and dignity of client.

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Cold hands will contract abdominal muscles and for clients comfort.

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Estimate fetal size; should be at the level of the xiphoid process at term 36 weeks; over the symphysis pubis at 12 weeks; at the umbilicus at 20 weeks.

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Facilitates examination by using the dominant hand.

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Identifies fetal lie and presentation

LEOPOLDS MANEUVER 1st Maneuver 13. Stand facing the head part of the client. If right handed stand on the right side, if left handed stands on the left side of the client. 14. Palpates the upper abdomen by putting palms of both hands on the side of the upper abdomen.

15. Identifies the fetal part that occupies

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One finds a mass which is either...