Physical Asessment

A. General Survey

Patient is 27 years old, stands 5’1 with pulse rate of 78 beats per minute with regular
rhythm upon palpation, respiratory rate of 18 cycles per minute, a temperature of 36.3 °C
and a blood pressure of 110/70. She is conscious and coherent upon interaction. Speech is
adequate and converses are well oriented.

B. Organ System Assessment

The Integumentary

Patient has brown skin complexion upon inspection. Skin on the right side of hand is
punctured due to intravenous fluid infusion with swelling, reddening, heat and pain noted.
Body hair is fine and thinly distributed. Skin is warm to touch, with skin turgor.

Head

Head is symmetrical upon inspection. Short, black, and wavy hair noted and evenly
distributed. Scalp is smooth and white in color, minimal lesions were noted. Lice were seen.
No masses noted upon palpation. Eyes are symmetrical upon inspection. Client has
brownish black eyes. Pupils are equal, round and reactive to light. No unusual discharges
from the lacrimal ducts noted upon palpation. Ears are symmetrical upon inspection
impacted cerumen noted in both ears suggesting poor hygiene. She reported no ear pain,
ringing in the ear or ear infection.

Neck

Neck muscles are symmetrical upon inspection. Skin on the neck is intact wih good skin
integrity. Carotid pulse is palpable. Trachea is at the center and immovable upon palpation.
No masses and lesions noted. Voice is clear and well-modulated.

Thorax and Lungs

No bulging masses observed at the posterior and anterior thorax. The posterior thorax
raises and goes down symmetrically when breathing. The posterior and anterior thorax was
warm and neither masses nor lesions palpated.

The Abdomen

The abdomen of the client was observed to have lower abdominal distension and is
supported by a binder. Skin integrity in the abdomen is intact with hypertrophic scar
approximately 4.5 inches long secondary to caesarean section note on the lower abdomen.
The Musculoskeletal

The client’s extremities were symmetric. And has even distribution of hair. The client’s
extremities were warm to touch. The client lower extremities were observed to be swollen.
The lower extremities was pinched and color turns back after 2 seconds.