REYES, Yoel Matthew H.

September 27, 2019

BSN2–1 Prof. Jennifer T. Mansing RN, MAN

Delivery Room: Assessment

I. Profile:

Name: Patient D
Sex Female
Age: 26 y/o
OB Score: G5P1
Occupation: Housewife
Nationality: Filipino
Date and Time of Admission: September 25, 2019, 8:30PM
LMP: February 14, 2019
AOG: 32 weeks
II. Physical Assessment:
Date Assessed: September 26, 2019
General Survey: 26 year-old client was received alert, oriented, cooperative, who appears weak
and drowsy
Vital Signs:
BP: 90/60 mmHG Temp: 36.4°C
PR: 94 bpm RR: 20 cpm

Part Technique Used Normal Findings Actual Findings Interpretation

Head
Evenly distributed Evenly distributed
Normal
Hair Inspection hair; thick hair; silky hair; thick hair; silky
resilient resilient

Inspection No infection or No infection or

infestation infestation Normal

Skull Inspection Normocephalic Normocephalic Normal

Symmetrical facial Symmetrical facial

Face Inspection Normal
features features
 Eyebrows are evenly
distributed
Inspection Eyelashes are
Eyebrows are
evenly distributed equally distributed Normal
Inspection
Eyelashes are
Eyelids skin intact, Normal
equally distributed
Eyes no discharge
Inspection
(External) Eyelids skin intact,
Eyelids close Normal
no discharge
symmetrically
Inspection
Eyelids close
Dark circles beneath Normal
symmetrically
eyes
Inspection
Abnormal

Inspection White sclera White sclera Normal

Inspection Palpebral Palpebral Normal

conjunctiva; shiny, conjunctiva; shiny,
smooth, and pink or smooth, and pink or
Eyes
red red
(Internal)
Inspection Pupils black in color, Pupils black in color, Normal
Both eyes Both eyes
coordinated move coordinated move in
in unison with unison with parallel
parallel alignment alignment
Inspection
Color same as Color same as facial
Ears Normal
facial skin skin

Inspection Outer lips pink in Outer lips pink in Normal

color, soft, moist color, soft, moist
smooth texture smooth texture

Inspection Symmetrical Symmetrical contour Normal

contour
Inspection Inner lips and buccal Normal
Inner lips and buccal mucosa appears
Mouth
mucosa appears uniform pink color,
uniform pink color, moist smooth,
moist smooth, glistening and elastic
glistening and
Inspection elastic Tongue central Normal
position, pink color,
Tongue central smooth, lateral
position, pink color, margins; no lesions,
smooth, lateral move freely
 margins; no lesions,
move freely
Inspection Neck muscles equal Neck muscles equal Normal
in size in size

Inspection Trachea in center of Trachea in center of Normal

Neck
the neck the neck

Inspection Thyroid glands not Thyroid glands not Normal

visible visible in inspection
Thorax and Inspection Full and symmetric Full and symmetric Normal
Lungs chest expansion chest expansion

Inspection Skin generally Skin is generally Normal

uniform except in uniform in color
areas exposed to
sun; varies from
light to dark brown

Scars and spots in Abnormal

skin can be seen
Upper
extremities upon inspection,

What appears to be Abnormal

insect bites can be
seen

Inspection, No edema No edema Normal

Palpation

Radial pulse is Weak pulsation, Abnormal

Cardiovascular
Palpation symmetrical and full asymmetrical but
system
pulsation is felt regular

Inspection Skin is uniform in Skin is lighter in color Physiologic

color, unblemished compared to the rest adaptation in
of the body, linea pregnancy
Abdomen, nigra is visible upon
Uterus inspection

Inspection Symmetrical Symmetrical contour Normal, due to

contour but changes upon presence of
movement fetus in the
womb
Musculoskeletal
Abnormal
System Inspection
Muscles equal in Muscles equal in both
both sides of the sides of the body; no
body; no pulsations pulsations or tremors;
or tremors; firm; firm; smooth and
smooth and coordinated. Appear
coordinated. Equal in generally weak upon
strength. inspection