PHYSICAL ASSESSMENT

A. GENERAL ASSESSMENT

The patient is a 40-year-old female who will give birth via NSVD. Her last menstrual

period (LMP) was March 19, 2019 and her estimated due date (EDD) will be on December

26, 2019. She has an obstetric score of G3P2. and her vital signs are as follows:

temperature: 36.9 °C, pulse rate: 98 beats per minute, respiratory rate: 21 breaths per

minute, and blood pressure: 110/80 mmHg. The patient is conscious, coherent, and alert.

B. ASSESSMENT OF THE HEAD

The head of the patient is round and firm. The hair is long, straight, and thick.

C. ASSESSMENT OF THE EYES

The eyes are round, symmetrical, and both move together. The conjunctiva is pink

and the sclera is white. Pupils are equally round and reactive to light accommodation. No

redness and no lesions noted. The patient has dark circles under her eyes.

D. ASSESSMENT OF THE EARS

The ears are of the same size, symmetrical in shape. No lesions were found.

Patient can hear words spoken in a whispered manner.

E. ASSESSMENT OF THE NOSE

The nose is at the midline of the face. No lesions were found and there is patency

on both nasal holes.

F. ASSESSMENT OF THE MOUTH

The mouth is at the midline of the face. Lips are moist and pink in color. The set of

teeth are complete. Gums are red in color and tongue is pinkish red in color.

G. ASSESSMENT OF THE SKIN

The skin of the patient is moist and light brown in color. No edema formation on

her arms and legs. There are no lesions noted.

H. ASSESSMENT OF THE LUNGS

The patient has a normal breathing pattern. No other sounds heard while she was

breathing.

I. ASSESSMENT OF THE HEART

The patient has a normal cardiac rate.

J. ASSESSMENT OF THE ABDOMEN

There is no rumbling or gurgling noise heard upon auscultation.

K. ASSESSMENT OF THE MUSCLES

The patient did not show any signs of weakness when moving her extremities and

she did not feel any pain or discomfort.