Question

1)_Discuss why documentation is important in nursing.                                             2)_Discuss the techniques and assessment of a pregnant adult female abdomen: Leopold’s maneuver.                                                3)_Discuss the techniques and assessment of depression in the older adult.

Answer 1

1. *Documentation = It is a written legal document pertaining to client care.

- It includes all written and electronics entries regarding all aspects of patient care communicated, planned, recommended or provided to the patient.

* Importance of documentation =  

- Communication

- Quality assurance

- Reimbursement

- Legal protection

- Research and evidence based practice

- Further planning

- Education

- Incidence and prevalence monitoring

- To calculate vital statistics.

* The major importance of documentation is recording and reporting all hospital related data .

2.  Leopold’s maneuver =

Leopold 's maneuver is also known as obsteric grip- palpation should be conducted with gentleness . clumsy and purposeless palpation is not only uniformative but may cause undue uterine irritability

Types=

A. Fundal grip - The palpation is done facing the patient's face . The whole of the fundal area is palpated using both hands laid flat on it to find out which pole of the fetus is lying in the fundus. Broad soft and irregular mass suggestive of breech, smooth, hard and globular mass suggestive of head.

B. Lateral or umblical grip= The palpation is done facing the patients face. The hands are to be placed flat on either side of the umblicus to palpate one after the other, the sides and front of the uterus to find out the positon of the back, limbs and anterior shoulder.

C. Pawlik grip = Also called third leopold = The examination is done facing toward the patient face. The overstretched thumb and four fingers of the right hand are placed over the lower pole of the uterus keeping the ulnar border of the palm on the upper border of the symphysis pubis. when the fingers and thums are approximated the presenting part is grasped distinctly and also the mobility from side to side is tested.

D. Pelvic grip = Also called fourth leopold . The examination is done facing the patient s feet The fingers are pressed downward and backward in a manner of approximatation of finger tips to palpate the part occupying the lower pole of the uterus .

3 Assessment of depression =

Answer = The assessment of depression is done by Questionary method .

In this technique many question asked by depressive patient related to depressed mood and loss of interest and question asked related to patient symptoms - Sleep disturbance , Appetite disturbance ,

Loss of energy, Difficulty cincentrating, Feelings of worthlessness,Suicidal thoughts etc and evaluate the patient through this and categorized the depression level mild moderate and severe.