ASSESSMENTS FOR THE NEWBORN BABIES Physical examination

A complete physical examination is an important part of

Apgar scoring
newborn care. Each body system is carefully examined for
The Apgar score is one of the first checks of your new baby's
signs of health and normal function. The doctor also looks for
health. The Apgar score is assigned in the first few minutes
any signs of illness or birth defects. Physical examination of a
after birth to help identify babies that have difficulty breathing
newborn often includes the assessment of the following:
or have a problem that needs further care. The baby is checked
at one minute and five minutes after birth for heart and Gestational assessment
respiratory rates, muscle tone, reflexes, and color. Apgar
Assessing a baby's physical maturity is an important part of
scores of three or less often mean a baby needs immediate
care. Maturity assessment is helpful in meeting a baby's needs
attention and care.
if the dates of a pregnancy are uncertain. For example, a very
Birthweight small baby may actually be more mature than it appears by
A baby's birthweight is an important indicator of health. The size, and may need different care than a premature baby.
average weight for term babies (born between 37 and 41
An examination called The Dubowitz/Ballard Examination for
weeks gestation) is about 7 lbs. (3.2 kg). In general, small
Gestational Age is often used. A baby's gestational age often
babies and very large babies are at greater risk for problems.
can be closely estimated using this examination. The
Babies are weighed daily in the nursery to assess growth,
Dubowitz/Ballard Examination evaluates a baby's appearance,
fluid, and nutrition needs. Newborn babies may often lose 5 to
skin texture, motor function, and reflexes. The physical
7 percent of their birthweight.
maturity part of the examination is done in the first two hours
Measurements of birth. The neuromuscular maturity examination is
Other measurements are also taken of each baby. These completed within 24 hours after delivery. Information often
include the following: used to help estimate babies' physical and neuromuscular
maturity are shown below.
 Head circumference. The distance around the baby's
head. Physical maturity
 Abdominal circumference. The distance around the
The physical assessment part of the Dubowitz/Ballard
abdomen.
Examination looks at physical characteristics that look
 Length. The measurement from crown of head to the different at different stages of a baby's gestational maturity.
heel. Babies who are physically mature usually have higher scores

 Vital signs: than premature babies.

 Temperature (able to maintain stable body Points are given for each area of assessment, with a low of -1
temperature in normal room environment) or -2 for extreme immaturity to as much as 4 or 5 for
 Pulse (normally 120 to 160 beats per minute postmaturity. Areas of assessment include the following:
in the newborn period)
 Skin textures (for example, sticky, smooth,
 Breathing rate (normally 40 to 60 breaths
or peeling).
per minute in the newborn period)
 Lanugo (the soft downy hair on a baby's
 General appearance. Physical activity, tone, posture,
body). Absent in immature babies, then appears with maturity,
and level of consciousness
and then disappears again with postmaturity.
 Skin. Color, texture, nails, presence of rashes
 Plantar creases. These creases on the soles of the feet
 Head and neck:
range from absent to covering the entire foot, depending on
 Appearance, shape, presence of molding
the maturity.
(shaping of the head from passage through the birth canal)
 Breast. The thickness and size of breast tissue and
 Fontanels (the open "soft spots" between the
areola (the darkened ring around each nipple) are assessed.
bones of the baby's skull)
 Eyes and ears. Eyes fused or open and amount of
 Clavicles (bones across the upper chest)
cartilage and stiffness of the ear tissue.
 Face. eyes, ears, nose, cheeks.
 Genitals, male. Presence of testes and appearance of
 Mouth. palate, tongue, throat.
scrotum, from smooth to wrinkled.
 Lungs. Breath sounds, breathing pattern.
 Genitals, female. Appearance and size of the clitoris
 Heart sounds and femoral (in the groin) pulses.
and the labia.
 Abdomen. Presence of masses or hernias.
Neuromuscular maturity
 Genitals and anus. For open passage of urine and
stool Six evaluations of the baby's neuromuscular system are
 Arms and legs. Movement and development. performed.
 A score is assigned to each assessment area. Typically, the standardized testing). Both methods are effective and can help
more neurologically mature the baby, the higher the score. The inform educators and parents about a child’s progress.
areas of assessment include:
 Observations can be made with minimal or no
 Posture. How does the baby hold his or her arms and
intrusion into children’s activities. Educators can observe all
legs.
facets of development, including intellectual, linguistic, social-
 Square window. How far the baby's hands can be
emotional, and physical development, on a regular basis.
flexed toward the wrist.
 Portfolios are a record of data that is collected
 Arm recoil. How much the baby's arms "spring back"
through the work children have produced over a period of
to a flexed position.
time. The collection clearly shows the progress of a child’s
 Popliteal angle. How far the baby's knees extend.
development. Portfolios can be an important tool in helping
 Scarf sign. How far the elbows can be moved across facilitate a partnership between teachers and parents.
the baby's chest.  Educator Ratings are useful in assessing children’s
 Heel to ear. How close the baby's feet can be moved cognitive and language abilities as well as their social-
to the ears. emotional development. These ratings can be linked to other

When the physical assessment score and the neuromuscular methods of assessment, such as standardized testing or other

score are added together, the gestational age can be estimated. assessment tools. (See the next question below.)

Scores range from very low for immature babies (less than 26  Parent Ratings integrate parents into the assessment

to 28 weeks) to very high scores for mature and postmature process. Parents who are encouraged to observe and listen to

babies. their child can help detect and target important milestones and
behaviors in their child’s development.
All of these examinations are important ways to learn about
 Standardized Tests are tests created to fit a set of
your baby's well-being at birth. By identifying any problems,
testing standards. These tests are administered and scored in a
your baby's doctor can plan the best possible care.
standard manner and are often used to assess the performance
of children in a program. 

ASSESSMENT FOR CHILDREN There are two different types of assessment systems. Both are

Early childhood assessment is a tool used to gather and used to guide decisions about a child’s development and

provide educators, parents, and families with critical program resources.

information about a child’s development and growth. 

1. Program-developed child assessment tools are
Childhood assessment is a process of gathering information developed to align with a specific program’s philosophy and
about a child, reviewing the information, and then using the curriculum.
information to plan educational activities that are at a level the 2. Published child assessment tools have been
child can understand and is able to learn from. researched and tested and are accepted as a credible source in

Assessment is a critical part of a high-quality, early childhood assessing children’s development.

program. 
The process of choosing the right assessment tools varies for
Observing and documenting a child’s work and performance each early childhood program. Below are some general
over the course of a year allows an educator to accumulate a guidelines for implementing assessment into your program.
record of the child’s growth and development. With this
 Assessment aligns with instructional goals and
information, educators can begin to plan appropriate
approaches. Different types of assessments have different
curriculum and effective individualized instruction for each
purposes. It is important to first determine what should be
child.
measured; then find the assessment program that best assesses
This assessment record is also a great tool to share with those goals.
parents so they can follow their child’s progress at school,  Assessor knows the child. The adult conducting the
understand their child’s strengths and challenges, and plan assessment should have a pre-existing relationship with the
how they can help extend the learning into their homes.  child. Ideally the assessor is the educator.
 Assessment is “authentic.” Assessment should take
Methods of child assessment can be informal (conducting
place in a child’s normal setting. The assessment should
natural observations, collecting data and children’s work for
reflect everyday relationships and experiences. It should be
portfolios, using educator and teacher ratings) and formal
conducted in familiar contexts and settings (such as the
(using assessment tools such as questionnaires and
classroom).
 Observations are ongoing and diverse. For a To estimate body fat, skinfold measurements can be made
comprehensive assessment, observations should be made at a using skin-fold calipers. Most frequently, tricep and
variety of children’s activities and be ongoing in order to fully subscapular (shoulder blade) skin-folds are measured.
see the progress of a child. Measurements can then be compared to reference data—and to
 Assessment is a cycle. Although specific methods for previous measurements of the individual, if available.
assessment tools vary, the process is cyclical. The cycle allows Accurate measuring takes practice, and comparison
educators to make changes to their curriculum to better serve measurements are most reliable if done by the same technician
children in their program. The cycle is as follows: each time.
o Instruct.
To estimate desirable body weight for amputees, and for
o Observe. Observe children in various
paraplegics and quadriplegics, equations have been developed
situations.
from cadaver studies, estimating desirable body weight, as
o Document, Reflect. Record while observing
well as calorie and proteinneeds. Calorie needs are
or as soon as possible.
determined by the height, weight, and age of an individual,
o Analyze, Evaluate. Study the data with
which determine an estimate of daily needs.
assessment tools. The assessment comes from the combination
of documentation and evaluation. The Harris-Benedict equation is frequently used, but there
o Summarize, Plan, and Communicate. This are quicker methods to estimate needs using just height and
informs a child’s specific needs and future curriculum. weight. Opinions and methods vary on how to estimate calorie
o Instruct. (The cycle repeats.) needs for the obese. As previously mentioned, body fat is less
metabolically active and requires fewer calories for support
NUTRITIONAL ASSESSMENT than muscle mass. If an individual's current body weight is
more than 125 percent of the desirable weight for the
A nutrition assessment is an in-depth evaluation of both individual's height and age, then using body weight to estimate
objective and subjective data related to an individual's food calories needs usually leads to an over-estimation of those
and nutrient intake, lifestyle, and medical history. needs.

Once the data on an individual is collected and organized, the

Biochemical data.
practitioner can assess and evaluate the nutritional status of
that person. The assessment leads to a plan of care, or Laboratory tests based on blood and urine can be important
intervention, designed to help the individual either maintain indicators of nutritional status, but they are influenced by
the assessed status or attain a healthier status. nonnutritional factors as well. Lab results can be altered by
medications, hydration status, and disease states or
Elements of the Assessment other metabolic processes, such as stress . As with the other
areas of nutrition assessment, biochemical data need to be
The data for a nutritional assessment falls into four
viewed as a part of the whole.
categories: anthropometric , biochemical , clinical, and
dietary.
Clinical data.

Anthropometrics. Clinical data provides information about the individual's

medical history, including acute and chronicillness and
Anthropometrics are the objective measurements of body
diagnostic procedures, therapies, or treatments that may
muscle and fat . They are used to compare individuals, to
increase nutrient needs or induce malabsorption . Current
compare growth in the young, and to assess weight loss or
medications need to be documented, and both
gain in the mature individual. Weight and height are the most
prescription drugs and over-the-counter drugs, such as
frequently used anthropometric measurements, and skinfold
laxatives or analgesics, must be included in the
measurements of several areas of the body are also taken.
analysis. Vitamins , minerals , and herbal preparations also
Determining frame size is an attempt at attributing weight to need to be reviewed. Physical signs of malnutrition can be
specific body compartments. Frame size identifies an documented during the nutrition interview and are an
individual relative to the bone size, but does not differentiate important part of the assessment process.
muscle mass from body fat. Because it is the muscle mass that
is metabolically active and the body fat that is associated with Dietary data.
disease states, Body Mass Index (BMI) is used to estimate the
There are many ways to document dietary intake. The
body-fat mass. BMI is derived from an equation using weight
accuracy of the data is frequently challenged, however, since
and height.
both questioning and observing can impact the actual intake. recommendations, is then formulated and discussed with the
During a nutrition interview the practitioner may ask what the individual.
individual ate during the previous twenty-four hours,
beginning with the last item eaten prior to the interview.
Practitioners can train individuals on completing a food diary,
PAIN ASSESSMENT
and they can request that the record be kept for either three
days or one week. Documentation should include portion sizes Pain assessment is critical to optimal pain management

and how the food was prepared. Brand names or the restaurant interventions. While pain is a highly subjective experience, its

where the food was eaten can assist in assessing the details of management necessitates objective standards of care. The

the intake. Estimating portion sizes is difficult, and requesting WILDA approach to pain assessment—focusing on words to

that every food be measured or weighed is time-consuming describe pain, intensity, location, duration, and aggravating or

and can be impractical. Food models and photographs of foods alleviating factors—offers a concise template for assessment

are therefore used to assist in recalling the portion size of the in patients with acute and chronic pain.

food. In a metabolic study, where accuracy in the quantity of Pain assessment usually begins with an open-ended inquiry:
what was eaten is imperative, the researcher may ask the “Tell me about your pain.” This allows the patient to tell his or
individual to prepare double portions of everything that is her story, including the aspects of the pain experience that are
eaten—one portion to be eaten, one portion to be saved (under most problematic. The clinician must listen closely to these
refrigeration, if needed) so the researcher can weigh or first words. Patients in pain want to tell their stories, and
measure the quantity and document the method of preparation. clinicians need to take time to listen. Stories are narratives that
provide meaning in our lives. They can teach, heal, validate,
Food frequency questionnaires are used to gather information
offer reflection, and shape how patients are cared for.
on how often a specific food, or category of food is eaten. The
Storytelling provides a different lens through which an
Food Guide Pyramid suggests portion sizes and the number of
experience can be viewed.
servings from each food group to be consumed on a daily
basis, and can also be used as a reference to evaluate dietary 5 key components to a pain assessment
intake.
Words
During the nutrition interview, data collection will include
A patient's statement, “I have pain,” is not descriptive enough
questions about the individual's lifestyle—including the
to inform a health care professional about pain type. Asking
number of meals eaten daily, where they are eaten, and who
patients to describe their pain using words will guide
prepared the meals. Information about allergies , food
clinicians to the appropriate interventions for specific pain
intolerances, and food avoidances, as well as caffeine and
types. Patients may have more than 1 type of pain. The
alcohol use, should be collected. Exercise frequency and
following questions should be asked of patients:
occupation help to identify the need for increased calories.
Asking about the economics of the individual or family, and
 What does your pain feel like?
about the use and type of kitchen equipment, can assist in
 Because various pain types are described using
the development of a plan of care. Dental and oral health also
different words, what words would you use to
impact the nutritional assessment, as well as information
describe the pain you are having?
about gastrointestinal health, such as problems
with constipation , gas or diarrhea, vomiting, or frequent
Neuropathic pain. This type of pain can be described as
heartburn.
burning, shooting, tingling, radiating, lancinating, or
numbness. Sometimes patients say that their pain is like a fire
Evaluation
or an electrical jolt. This type of pain can be due to nerve
disorders; nerve involvement by a tumor pressing on cervical,
After data are collected, the practitioner uses past experience
brachial, or lumbosacral plexi; postherpetic neuralgia; or
as well as reference standards to assimilate the information
peripheral neuropathies secondary to treatment
into an assessment that provides an understanding of the
(chemotherapy, radiation fibrosis). Typically, opioids alone
individual's nutritional status. The practitioner uses the
will not help neuropathic pain; antidepressants,
anthropometric data to assess ideal and desirable weight, as
anticonvulsants, and benzodiazepines may be used as an
well as skinfold measurements to determine body fat. Height,
adjuvant treatment.
weight, and age are plugged into the Harris-Benedict equation
to determine calorie and protein needs. Using the clinical, Somatic pain. Described as achy, throbbing, or dull, somatic
biochemical, and dietary data, influences on the nutritional pain is typically well localized. Somatic pain accompanies
status can be determined. A nutritional intervention, which arthritis, bone or spine metastases, low back pain, and
usually includes dietary guidance and exercise orthopaedic procedures. Nonsteroidal anti-inflammatory drugs
are the treatment of choice in patients who can tolerate them “Do you have both chronic and breakthrough pain?” Pain
(i.e., those who are not at risk for gastrointestinal bleeding or descriptors, intensity, and location are important to obtain not
renal failure). Additionally, muscle relaxants, bone-seeking only on breakthrough pain but on stable (continuous) pain as
radiopharmaceuticals such as strontium 89 (Metastron), well.
certain biphosphonates (pamidronate), and opioid drugs can
also be helpful. Aggravating/alleviating factors

Visceral pain. Pain described as squeezing, pressure, Asking the patient to describe the factors that aggravate or
cramping, distention, dull, deep, and stretching is visceral in alleviate the pain will help plan interventions. A typical
origin. Visceral pain is manifested in patients after abdominal question might be, “What makes the pain better or worse?”
or thoracic surgery. It also occurs secondary to liver Analgesics, nonpharmacologic approaches (massage,
metastases or bowel or venous obstruction. Opioids are the relaxation, music or visualization therapy, biofeedback, heat or
treatment of choice. However, caution should be taken when cold), and nerve blocks are some interventions that may
using this class of drugs with patients who have bowel relieve the pain. Other factors (movement, physical therapy,
obstructions. activity, intravenous sticks or blood draws, mental anguish,
depression, sadness, bad news) may intensify the pain.
Intensity
Other things to include in the pain assessment are the presence
The ability to quantify the intensity of pain is essential when of contributing symptoms or side effects associated with pain
caring for persons with acute and chronic pain. Though no and its treatment. These include nausea, vomiting,
scale is suitable for all patients, Dalton and McNaull (18) constipation, sleepiness, confusion, urinary retention, and
advocate a universal adoption of a 0 to 10 scale for clinical weakness. Some patients may tolerate these symptoms without
assessment of pain intensity in adult patients. Standardization aggressive treatment; others may choose to stop taking
may promote collaboration and consistency among caregivers analgesics or adjuvant medications because of side effect
in multiple settings—inpatient, outpatient, and home care intolerance. Adjustments, alterations, or titration may be all
environments. Using a pain scale with 0 being no pain and 10 that is necessary.
being the worst pain imaginable, a numerical value can be
Inquiring about the presence or absence of changes in appetite,
assigned to the patient's perceived intensity of pain. Asking
activity, relationships, sexual functioning, irritability, sleep,
patients to rate their present pain, their pain after an
anxiety, anger, and ability to concentrate will help the
intervention, and their pain over the past 24 hours will enable
clinician understand the pain experience in each individual.
health care providers to see if the pain is worsening or
Additionally, the clinician should discern how pain is
improving. Also, inquiring about the pain level acceptable to
perceived by the patient and his or her family or significant
the patient will help clinicians understand the patient's goal of
other and what works and doesn't work to help the pain.
therapy. The Wong/Baker faces rating scale is a visual
representation of the numerical scale (19) (Figure (Figure22). PATIENTS' KNOWLEDGE AND BELIEFS ABOUT PAIN
Although the faces scale was developed for use in pediatric
patients, it has also proven useful with elderly patients and Patients' knowledge and beliefs about pain are assumed to play

patients with language barriers. a role in pain perception, function, and response to treatment
(21). Patients may be reluctant to tell their health care
providers when they have pain, may attempt to minimize its
Location severity, may not know they can expect pain relief, and may
be concerned about taking pain medications for fear of
Most patients have 2 or more sites of pain. Thus, it is
deleterious effects. A comprehensive approach to pain
important to ask patients, “Where is your pain?” or “Do you
assessment includes evaluating patients' knowledge and beliefs
have pain in more than one area?” The pain that the patient
about pain and its management and reviewing common
may be referring to may be different than the one the nurse or
misconceptions about analgesia. Several common myths need
physician is talking about. Having the patient point to the
to be discussed openly:
painful area can be more specific and help to determine
interventions.  Pain is a part of life. I just need to bear it.
 I shouldn't take my pain medication until I really
Duration
need it or else it won't work later.
Breakthrough pain refers to a transitory exacerbation or flare  I don't want to become an addict.
of pain occurring in an individual who is on a regimen of  I don't want to get constipated so I'd better not take
analgesics for continuous stable pain (20). Patients need to be my pain medication.
asked, “Is your pain always there, or does it come and go?” or
  I don't want to bother the doctor or nurse; they're sign of acute pain, treatment with analgesics or
busy with other patients. nonpharmacologic measures may be helpful. If a
 If it's morphine, I must be getting close to the end. modification of pain behavior occurs, pain treatment
 My family thinks I get confused on pain medication; should be continued with an explanation to the
I'd better not take it. patient and family.

Discussing these myths during the assessment process not only

legitimizes patients' concerns but provides an opportunity to
GERIATRIC ASSESEEMENT
educate patients and families about pain medications and how
they work. At times patients and family members believe that
The geriatric assessment is a multidimensional,
behavior such as complaining about pain or inadequate pain
multidisciplinary assessment designed to evaluate an
relief may result in substandard care (22). Realizing that they
older person's functional ability, physical health,
have limited time with their health care providers, patients
cognition and mental health, and socioenvironmental
may prioritize the time available to them. Assuming that
circumstances. It is usually initiated when the
“good” patients will receive more time and attention, patients
physician identifies a potential problem. Specific
decide for themselves that discomfort is not part of the good
elements of physical health that are evaluated include
patient role. This is another misconception to discuss with the
nutrition, vision, hearing, fecal and urinary
patient.
continence, and balance. The geriatric assessment aids
in the diagnosis of medical conditions; development of
ASSESSING PAIN IN NONVERBAL OR COGNITIVELY
treatment and follow-up plans; coordination of
IMPAIRED PATIENTS
management of care; and evaluation of long-term care
Patients' self-report is the gold standard of pain assessment. needs and optimal placement. The geriatric assessment
However, pain tools that rely on verbal self-report, such as the differs from a standard medical evaluation by
0 to 10 numeric rating scale, may not be appropriate for use in including nonmedical domains; by emphasizing
nonverbal or cognitively impaired patients. Additionally, functional capacity and quality of life; and, often, by
reliance on nonverbal cues—e.g., changes in vital signs, incorporating a multidisciplinary team. It usually
moaning, facial grimacing, or muscle tenseness—is not yields a more complete and relevant list of medical
practical or reliable. Diverse responses to pain atypical of problems, functional problems, and psychosocial
conventional pain behaviors have been noted in patients with issues. Well-validated tools and survey instruments for
Alzheimer's disease by Marzinski (23). For example, a patient evaluating activities of daily living, hearing, fecal and
who normally rocked and moaned became quiet and urinary continence, balance, and cognition are an
withdrawn when experiencing pain. important part of the geriatric assessment. Because of
the demands of a busy clinical practice, most geriatric
It is important to obtain feedback from the patient by asking
assessments tend to be less comprehensive and more
the patient to nod his head, squeeze your hand, move his eyes
problem-directed. When multiple concerns are
up and down, or raise his fingers, hand, arm, or leg to signal
presented, the use of a “rolling” assessment over
the presence of pain. If appropriate, offer writing materials,
several visits should be considered.
pain intensity charts, or figures that the patient can point to.
The following questions can be used as a template for
Functional Ability
assessment of pain in the nonverbal patient:
Functional status refers to a person's ability to perform tasks
 After reviewing the patient's history, is there a reason that are required for living. The geriatric assessment begins
for this patient to be experiencing pain? with a review of the two key divisions of functional ability:

 When the patient experienced pain in the past, how activities of daily living (ADL) and instrumental activities of

did he or she usually act? (Note: the daily living (IADL). ADL are self-care activities that a person

family/significant other or other health care providers performs daily (e.g., eating, dressing, bathing, transferring

may need to be questioned about this.) between the bed and a chair, using the toilet, controlling

 What is the family/significant other's thoughts or bladder and bowel functions). IADL are activities that are

interpretation of the patient's behavior? Do they needed to live independently (e.g., doing housework,

believe that the patient is having pain? Why do they preparing meals, taking medications properly, managing

feel this way? finances, using a telephone).

 Has the patient been treated for pain previously?

Physical Health
What pharmacologic or nonpharmacologic
The geriatric assessment incorporates all facets of a
interventions were used? If there is a reason for or a
conventional medical history, including main problem, current
illness, past and current medical problems, family and social and the whispered voice test are also recommended. The
history, demographic data, and a review of systems. The whispered voice test is performed by standing approximately 3
approach to the history and physical examination, however, ft behind the patient and whispering a series of letters and
should be specific to older persons. In particular, topics such numbers after exhaling to assure a quiet whisper. Failure to
as nutrition, vision, hearing, fecal and urinary continence, repeat most of the letters and numbers indicates hearing
balance and fall prevention, osteoporosis, and polypharmacy impairment.19 As part of the Medicare-funded initial
should be included in the evaluation. preventive physical examination, physicians are encouraged to
use hearing screening questionnaires to evaluate an older
SCREENING FOR DISEASE
patient's functional ability and level of safety.
In the normal aging process, there is often a decline in
physiologic function that is usually not disease-related. URINARY CONTINENCE

However, treatment of diabetes mellitus, hypertension, and Urinary incontinence, the unintentional leakage of urine,
glaucoma can prevent significant future morbidity. Screening affects approximately 15 million persons in the United States,
for malignancies may allow for early detection, and some are most of whom are older. 24 Urinary incontinence has important
curable if treated early. It is important that physicians weigh medical repercussions and is associated with decubitus ulcers,
the potential harms of screening before screening older sepsis, renal failure, urinary tract infections, and increased
patients. It is essential to consider family preferences mortality. Psychosocial implications of incontinence include
regarding treatment if a disease is detected, and the patient's loss of self-esteem, restriction of social and sexual activities,
functional status, comorbid conditions, and predicted life and depression. Additionally, incontinence is often a key
expectancy. If an asymptomatic patient has an expected deciding factor for nursing home placement. 25 An assessment
survival of more than five years, screening is generally for urinary incontinence should include the evaluation of fluid
medically warranted, assuming that the patient is at risk of the intake, medications, cognitive function, mobility, and previous
disease and would accept treatment if early disease was urologic surgeries.
detected.
BALANCE AND FALL PREVENTION
NUTRITION Impaired balance in older persons often manifests as falls and
A nutritional assessment is important because inadequate fall-related injuries. Approximately one-third of community-
micronutrient intake is common in older persons. Several age- living older persons fall at least once per year, with many
related medical conditions may predispose patients to vitamin falling multiple times.27,28 Falls are the leading cause of
and mineral deficiencies. Studies have shown that vitamins A, hospitalization and injury-related death in persons 75 years
C, D, and B12; calcium; iron; zinc; and other trace minerals are and older.29
often deficient in the older population, even in the absence of
The Tinetti Balance and Gait Evaluation is a useful tool to
conditions such as pernicious anemia or malabsorption. 12 
assess a patient's fall risk. 28,30 This test involves observing as a
There are four components specific to the geriatric nutritional
patient gets up from a chair without using his or her arms,
assessment: (1) nutritional history performed with a nutritional
walks 10 ft, turns around, walks back, and returns to a seated
health checklist; (2) a record of a patient's usual food intake
position. This entire process should take less than 16 seconds.
based on 24-hour dietary recall; (3) physical examination with
Those patients who have difficulty performing this test have
particular attention to signs associated with inadequate
an increased risk of falling and need further evaluation.
nutrition or overconsumption; and (4) select laboratory tests, if
applicable. One simple screening tool for nutrition in older
OSTEOPOROSIS
persons is the Nutritional Health Checklist 
Osteoporosis may result in low-impact or spontaneous
VISION fragility fractures, which can lead to a fall. 14Osteoporosis can
be diagnosed clinically or radiographically.34 It is most
The most common causes of vision impairment in older
commonly diagnosed by dual-energy x-ray absorptiometry of
persons include presbyopia, glaucoma, diabetic retinopathy,
the total hip, femoral neck, or lumbar spine, with a T-score of
cataracts, and age-related macular degeneration.
–2.5 or below.35,36 The USPSTF has advised routinely
HEARING screening women 65 years and older for osteoporosis with

Presbycusis is the third most common chronic condition in dual-energy x-ray absorptiometry of the femoral neck.37

older Americans, after hypertension and arthritis. 17 The

POLYPHARMACY
USPSTF is updating its 1996 recommendations, but currently
Polypharmacy, which is the use of multiple medications or the
recommends screening older patients for hearing impairment
administration of more medications than clinically indicated,
by periodically questioning them about their
is common in older persons. Among older adults, 30 percent
hearing.18 Audioscope examination, otoscopic examination,
of hospital admissions and many preventable problems, such
as falls and confusion, are believed to be related to adverse that includes any condition or event requiring new or ongoing
38
drug effects.  The Centers for Medicare and Medicaid care; the medical, nutritional, functional, and social
Services encourages the use of the Beers criteria, which list implications; and proposed interventions. This type of
medication and medication classes that should be avoided in assessment allows older patients to benefit from an
older persons, as part of an older patient's medication interdisciplinary team that is effectively assessing and actively
assessment to reduce adverse effects. managing their health care.

Cognition and Mental Health

DEPRESSION
OBSTETRICAL ASSESSMENT
The USPSTF recommends screening adults for depression if
systems of care are in place.42 Of the several validated Ideally, women who are planning to become pregnant should
screening instruments for depression, the Geriatric Depression see a physician before conception; then they can learn about
Scale and the Hamilton Depression Scale are the easiest to use pregnancy risks and ways to reduce risks. As part of
43
and most widely accepted.  However, a simple two-question preconception care, primary care clinicians should advise all
screening tool (“During the past month, have you been women of reproductive age to take a vitamin that contains
bothered by feelings of sadness, depression, or hopelessness?” folic acid 400 to 800 mcg (0.4 to 0. 8 mg) once/day. Folate
and “Have you often been bothered by a lack of interest or reduces risk of neural tube defects. If women have had a
pleasure in doing things?”) is as effective as these longer fetus or infant with a neural tube defect, the recommended
scales.43,44 Responding in the affirmative to one or both of daily dose is 4000 mcg (4 mg). Taking folate before and after
these questions is a positive screening test for depression that conception may also reduce the risk of other birth defects
requires further evaluation. (1).
Once pregnant, women require routine prenatal care to help
DEMENTIA safeguard their health and the health of the fetus. Also,
Early diagnosis of dementia allows patients timely access to evaluation is often required for symptoms and signs of
medications and helps families to make preparations for the illness. Common symptoms that are often pregnancy-related
future. It can also help in the management of other symptoms include
that often accompany the early stages of dementia, such as
depression and irritability. As few as 50 percent of dementia  Vaginal bleeding

cases are diagnosed by physicians.45  There are several  Pelvic pain

screening tests available to assess cognitive dysfunction;  Vomiting

however, the Mini-Cognitive Assessment Instrument is the  Lower-extremity edema
preferred test for the family physician because of its speed, For specific obstetric disorders, see Abnormalities of
convenience, and accuracy, as well as the fact that it does not Pregnancy; for nonobstetric disorders in pregnant women,
require fluency in English see Pregnancy Complicated by Disease .
The initial routine prenatal visit should occur between 6
Socioenvironmental Circumstances
and 8 wk gestation.
According to the U.S. Census Bureau, approximately 70 Follow-up visits should occur at
percent of noninstitutionalized adults 65 years and older live  About 4-wk intervals until 28 wk
with their spouses or extended family, and 30 percent live  2-wk intervals from 28 to 36 wk
48
alone.  Determining the most suitable living arrangements for  Weekly thereafter until delivery
older patients is an important function of the geriatric
assessment. Although options for housing for older persons Prenatal visits may be scheduled more frequently if risk of a
vary widely, there are three basic types: private homes in the poor pregnancy outcome is high or less frequently if risk is
community, assisted living residences, and skilled nursing very low.
facilities (e.g., rehabilitation hospitals, nursing homes).
Prenatal care includes
Factors affecting the patient's socioenvironmental
circumstances include their social interaction network,
 Screening for disorders
available support resources, special needs, and environmental
 Taking measures to reduce fetal and maternal risks
safety.
 Counseling
Problem List
History
As assessment data are obtained, they need to be recorded to
allow all members of the health care team to easily access the
During the initial visit, clinicians should obtain a full
information. The family physician can generate a problem list
medical history, including
  Previous and current disorders  Pelvic capacity can be estimated clinically by
 Drug use (therapeutic, social, and illicit) evaluating various measurements with the middle
 Risk factors for complications of pregnancy (see finger during bimanual examination. If the distance
Table: Risk Factors for Complications During from the underside of the pubic symphysis to the
Pregnancy) sacral promontory is > 11.5 cm, the pelvic inlet is

 Obstetric history, with the outcome of all previous almost certainly adequate. Normally, distance

pregnancies, including maternal and fetal between the ischial spines is ≥ 9 cm, length of the

complications (eg, gestational diabetes, preeclampsia, sacrospinous ligaments is 4 to ≥ 5 cm, and the

congenital malformations, stillbirth) subpubic arch is ≥ 90°.

 During subsequent visits, BP and weight assessment
Family history should include all chronic disorders in family is important. Obstetric examination focuses on
members to identify possible hereditary disorders uterine size, fundal height (in cm above the
(see Genetic Evaluation). symphysis pubis), fetal heart rate and activity, and
During subsequent visits, queries focus on interim maternal diet, weight gain, and overall well-being.
developments, particularly vaginal bleeding or fluid Speculum and bimanual examination is usually not
discharge, headache, changes in vision, edema of face or needed unless vaginal discharge or bleeding,
fingers, and changes in frequency or intensity of fetal leakage of fluid, or pain is present.
movement.  Testing

Gravidity and parity  Laboratory testing

Gravidity is the number of confirmed pregnancies; a  Prenatal evaluation involves urine tests and blood
pregnant woman is a gravida. Parity is the number of tests. Initial laboratory evaluation is thorough; some
deliveries after 20 wk. Multifetal pregnancy is counted as components are repeated during follow-up visits
one in terms of gravidity and parity. Abortus is the number (see Table: Components of Routine Prenatal
of pregnancy losses (abortions) before 20 wk regardless of Evaluation).
cause (eg, spontaneous, therapeutic, or elective abortion; If a woman has Rh-negative blood, she may be at risk of
ectopic pregnancy). Sum of parity and abortus equals developing Rh0(D) antibodies, and if the father has Rh-
gravidity. positive blood, the fetus may be at risk of
developing erythroblastosis fetalis . Rh0(D) antibody levels
Parity is often recorded as 4 numbers:
should be measured in pregnant women at the initial prenatal

 Number of term deliveries (after 37 wk) visit and again at about 26 to 28 wk. At that time, women

 Number of premature deliveries (> 20 and < 37 wk) who have Rh-negative blood are given a prophylactic dose of
Rh0(D) immune globulin. Additional measures may be
 Number of abortions
necessary to prevent development of maternal Rh antibodies.
 Number of living children
Generally, women are routinely screened for gestational
Thus, a woman who is pregnant and has had one term diabetes between 24 and 28 wk using a 50-g, 1-h glucose
delivery, one set of twins born at 32 wk, and 2 abortions is tolerance test. However, if women have significant risk
gravida 5, para 1-1-2-3. factors for gestational diabetes, they are screened during the
1st trimester. These risk factors include
Physical Examination  Gestational diabetes  or a macrosomic neonate
(weight > 4500 g at birth) in a previous pregnancy
A full general examination, including BP, height, and  Unexplained fetal losses
weight, is done first. BMI should be calculated and recorded.
 A strong family history of diabetes in 1st-degree
BP and weight should be measured at each prenatal visit.
relatives
 A history of persistent glucosuria
In the initial obstetric examination, speculum and bimanual
pelvic examination is done for the following reasons:  Body mass index (BMI) > 30 kg/m 2
 Polycystic ovary syndrome  with insulin resistance
 To check for lesions or discharge If the 1st-trimester test is normal, the 50-g test should
 To note the color and consistency of the cervix repeated at 24 to 28 wk, followed, if abnormal, by a 3-h test.
 To obtain cervical samples for testing Abnormal results on both tests confirms the diagnosis of
 Also, fetal heart rate and, in patients presenting later gestational diabetes.
in pregnancy, lie of the fetus are assessed (see
Figure: Leopold maneuver. ).
Women at high risk of aneuploidy (eg, those > 35 yr, those Ultrasonography is also used for needle guidance
who have had a child with Down syndrome) should be during chorionic villus sampling , amniocentesis, and fetal
offered screening with maternal serum cell-free DNA . transfusion. High-resolution ultrasonography includes
In some pregnant women, blood tests to screen for thyroid techniques that maximize sensitivity for detecting fetal
disorders (measurement of thyroid-stimulating hormone malformations.
[TSH]) are done. These women may include those who If ultrasonography is needed during the 1st trimester (eg, to
evaluate pain, bleeding, or viability of pregnancy), use of an
 Have symptoms endovaginal transducer maximizes diagnostic accuracy;
 Come from an area where moderate to severe iodine evidence of an intrauterine pregnancy (gestational sac or
insufficiency occurs fetal pole) can be seen as early as 4 to 5 wk and is seen at 7
 Have a family or personal history of thyroid to 8 wk in > 95% of cases. With real-time ultrasonography,
disorders fetal movements and heart motion can be directly observed
 Have type 1 diabetes as early as 5 to 6 wk.
 Have a history of infertility, preterm delivery, or Other imaging
miscarriage Conventional x-rays can induce spontaneous abortion or
 Have had head or neck radiation therapy congenital malformations, particularly during early
 Are morbidly obese (BMI > 40 kg/m ) 2
pregnancy. Risk is remote (up to about 1/million) with each
 Are > 30 yr x-ray of an extremity or of the neck, head, or chest if the
uterus is shielded. Risk is higher with abdominal, pelvic, and
Ultrasonography lower back x-rays. Thus, for all women of childbearing age,
Most obstetricians recommend at least one ultrasound an imaging test with less ionizing radiation (eg,
examination during each pregnancy, ideally between 16 and ultrasonography) should be substituted when possible, or if
20 wk, when estimated delivery date (EDD) can still be x-rays are needed, the uterus should be shielded (because
confirmed fairly accurately and when placental location and pregnancy is possible).
fetal anatomy can be evaluated. Estimates of gestational age
are based on measurements of fetal head circumference, Medically necessary x-rays or other imaging should not be
biparietal diameter, abdominal circumference, and femur postponed because of pregnancy. However, elective x-rays
length. Measurement of fetal crown-rump length during the are postponed until after pregnancy.
1st trimester is particularly accurate in predicting EDD: to
Treatment
within about 5 days when measurements are made at < 12 wk
gestation and to within about 7 days at 12 to 15 wk.
Problems identified during evaluation are managed.
Ultrasonography during the 3rd trimester is accurate for
predicting EDD to within about 2 to 3 wk. Women are counseled about exercise and diet and advised to
Specific indications for ultrasonography  include follow the Institute of Medicine guidelines for weight gain,
 Investigation of abnormalities during the 1st which are based on prepregnancy body mass index (BMI—
trimester (eg, indicated by abnormal results of see Table: Guidelines for Weight Gain During Pregnancy* ).
noninvasive maternal screening tests) Nutritional supplements are prescribed.
 Risk assessment for chromosomal abnormalities (eg, What to avoid, what to expect, and when to obtain further
Down syndrome) including nuchal translucency evaluation are explained. Couples are encouraged to attend
measurement childbirth classes.
 Need for detailed assessment of fetal anatomy
(usually at about 16 to 20 wk), possibly including Diet and supplements

fetal echocardiography at 20 wk if risk of congenital To provide nutrition for the fetus, most women require about

heart defects is high (eg, in women who have type 1 250 kcal extra daily; most calories should come from protein.

diabetes or have had a child with a congenital heart If maternal weight gain is excessive (> 1.4 kg/mo during the

defect) early months) or inadequate (< 0.9 kg/mo), diet must be

 Detection of multifetal pregnancy, hydatidiform modified further. Weight-loss dieting during pregnancy is

mole, polyhydramnios, placenta previa, or ectopic not recommended, even for morbidly obese women.

pregnancy Most pregnant women need a daily oral iron supplement

 Determination of placental location, fetal position of ferrous sulfate 300 mg or ferrous gluconate 450 mg, which

and size, and size of the uterus in relation to given may be better tolerated. Woman with anemia should take the

gestational dates (too small or too large) supplements bid.

All women should be given oral prenatal vitamins that
contain folate 400 mcg (0.4 mg), taken once/day; folate
reduces risk of neural tube defects. For women who have had  Exposure to chemicals or paint fumes
a fetus or infant with a neural tube defect, the recommended  Direct handling of cat litter (due to risk of
daily dose is 4000 mcg (4 mg). toxoplasmosis)
 Prolonged temperature elevation (eg, in a hot tub or
Physical activity
sauna)
Pregnant women can continue to do moderate physical
 Exposure to people with active viral infections (eg,
activities and exercise but should take care not to injure the
rubella, parvovirus infection [fifth disease], varicella)
abdomen.

Women with substance abuse problems should be monitored

Sexual intercourse can be continued throughout pregnancy
by a specialist in high-risk pregnancy . Screening for
unless vaginal bleeding, pain, leakage of amniotic fluid, or
domestic violence and depression should be done.
uterine contractions occur.
Drugs and vitamins that are not medically indicated should

Travel be discouraged (see Drugs in Pregnancy ).

The safest time to travel during pregnancy is between 14 and Symptoms requiring evaluation

28 wk, but there is no absolute contraindication to travel at Women should be advised to seek evaluation for unusual

any time during pregnancy. Pregnant women should wear headaches, visual disturbances, pelvic pain or cramping,

seat belts regardless of gestational age and type of vehicle. vaginal bleeding, rupture of membranes, extreme swelling of
the hands or face, diminished urine volume, any prolonged
Travel on airplanes is safe until 36 wk gestation. The illness or infection, or persistent symptoms of labor.
primary reason for this restriction is the risk of labor and
delivery in an unfamiliar environment. Multiparous women with a history of rapid labor should
notify the physician at the first symptom of labor.
During any kind of travel, pregnant women should stretch
and straighten their legs and ankles periodically to prevent
venous stasis and the possibility of thrombosis. For example,
on long flights, they should walk or stretch every 2 to 3 h. In
some cases, the clinician may recommend
thromboprophylaxis for prolonged travel.

Immunizations
Vaccines  for measles, mumps, rubella, and varicella should
not be used during pregnancy. The hepatitis B vaccine can be
safely used if indicated, and the influenza vaccine is strongly
recommended for women who are pregnant or postpartum
during influenza season. Booster immunization for
diphtheria, tetanus, and pertussis (Tdap) between 27 and 36
wk gestation or postpartum is recommended, even if women
have been fully vaccinated.
Because pregnant women with Rh-negative blood are at risk
of developing Rh0(D) antibodies, they are given
Rh0(D) immune globulin 300 mcg IM in any of the following
situations:
 After any significant vaginal bleeding or other sign
of placental hemorrhage or separation (abruptio
placentae)
 After a spontaneous or therapeutic abortion
 After amniocentesis or chorionic villus sampling
 Prophylactically at 28 wk
 If the neonate has Rh 0(D)-positive blood, after
delivery
Modifiable risk factors
Pregnant women should not use alcohol and tobacco and
should avoid exposure to secondhand smoke. They should
also avoid the following: