XI.

HEALTH ASSESSMENT

A. General Survey

The patient was received conscious at the ER, lying down on bed on a supine position. With appropriate
expressions and cooperative, speech clear, clothing appropriate to climate, looks clean and fit and
appears clean and well groomed. Patient appears to the age reported which is 27 years old and
pregnant at 27 weeks gestation. Patient appears weak, tired also has high pain threshold and irritable.
Limited movement due to pain being felt on head.

B. Head to Toe Assessment

1. Head The head is rounded, normocephalic and

symmetrical and the hair is thick, silky hair is
evenly distributed and has a variable amount
of body hair. There are also no signs
of infection and infestation observed. The
face appeared smooth and has uniform
consistency and with no presence of nodules
or masses.
2. Eyes Eyebrows are present bilaterally, move
symmetrically as the facial expression
changes, and have no scaling or lesions. The
eyelashes are evenly distributed along the lid
margins and curve outward. There were no
presence of discharges, no discoloration and
lids close symmetrically with involuntary
blinks approximately 15-20 times per minute.
The Bulbar conjunctiva appeared transparent
with few capillaries evident. The sclera
appeared white. The palpebral conjunctiva
appeared shiny, smooth and pink. There is no
edema or tearing of the lacrimal gland.
Cornea is transparent, smooth and shiny and
the details of the iris are visible. The client
blinks when the cornea was touched. The
pupils of the eyes are black and equal in size.
The iris is flat and round. PERRLA (pupils
equally round respond to light
accommodation), illuminated and non-
illuminated pupils constricts. Pupils constrict
when looking at near object and dilate at far
object. Pupils converge when object is moved
towards the nose. Not able to perform 6 field
of gaze. The patient was able only to identify
primary colors by wearing corrective glasses
 as the patient mentioned that was diagnosed
with astigmatism.
3. Ears The patient’s auricles are symmetrical and
has the same color with his facial skin. The
auricles are aligned with the outer canthus
of eye. When palpating for the texture, the
auricles are mobile, firm and not tender. The
pinna recoils when folded. During the
assessment of Watch tick test, the client was
able to hear ticking in both ears and has
minimal presence of cerumen.
4. Nose and sinuses The nose appeared symmetric, straight and
uniform in color. There was no presence of
discharge or flaring. When lightly palpated,
there were no tenderness and lesions,
inflammatory, or nodules on the frontal,
sphenoid, ethnocide and maxillary sinuses.
No noted pain.
5. Mouth The lips of the client are dry with crack and
darken in color has teeth cavities and dental
carries. Oral mucosa is not dry and pink in
color. Tonsils are bilaterally present and not
inflamed. Uvula is located at midline of the
soft palate and with complete set of teeth.
Not wearing any dentures. The client was
able to purse his lips when asked to whistle.
The tongue of the client is centrally
positioned. It is pink in color, moist and
slightly rough. There is a presence of thin
whitish coating. The smooth palates are light
pink and smooth while the hard palate has a
more irregular texture.
6. Neck The neck muscles are equal in size. The client
showed coordinated, smooth head
movement with no discomfort.
The lymph nodes of the client are not
palpable. The trachea is placed in the midline
of the neck. The thyroid gland is not visible
on inspection and the glands ascend during
swallowing but are not visible.
7. Chest Chest is symmetrical, has lighter complexion
as compared to the patient all over skin
color. No lumps, masses, and nodules
palpated. No sounds of crackles, crepitus and
wheeze.
There’s a full and symmetric expansion and
the thumbs separate 2-3 cm during
deep inspiration when assessing for the
respiratory excursion. The client manifested
quiet, rhythmic and effortless respirations.
8. Cardiac The fetal heart tone (FHT) was 150bpm and
good was observed with good fetal
movement.
There is also a decrease in the blood pressure
ranging from 190/100mmHg to
160/110mmHg (normal range: 120/80mmHg-
130/90mmHg).
9. Breast/Chest  Breast are round and symmetrical upon
observation. Patient stated that there are no
masses and tenderness upon palpation and
secretion. A delicate, blue vascular pattern is
visible over the breasts of lightly pigmented
females. The patient’s breasts increase in
size, as do the nipples. No pain noted during
self-examination of breast.
10. Abdomen Patient’s abdomen is unblemished skin,
uniform in color, symmetric contour, not
distended. There were symmetric
movements caused associated with client’s
respiration and fetal heart tones. Tympany
over intestines. Dull over enlarging uterus.
Single curve. Umbilicus protruding. Bowel
sounds diminished. Tympany over intestines.
Dull over enlarging uterus.
11. Genitals The patient reported having a decreased
urine output wherein she only urinated lately
thrice a day.
12. Musculoskeletal Patient has no problem in doing range of
motion on both extremities. Muscles are
equal in size both sides of the body, smooth
coordinated movements, 100% of normal full
movement against gravity and full resistance.
The bones and joints have no deformities or
 swelling, joints move smoothly.
13. Integumentary Skin is light brown in complexion with
presence of paleness. The skin is cool when
touched. With presence of edema on her
hand. Capillary Refill is 3 seconds suggest
dehydration for skin turgor takes longer than
usual for the skin to bounce back. When nails
pressed between the fingers (Blanch Test),
the nails return to usual color in less than 4
seconds.
14. Reproductive Patient’s quantity of pubic hair was
consistent with sexual maturity expected for
the patient’s age. No presence of lice and
scabies and fleas. No presence of lesion.
Patient’s first menstruation was in her 13
years of age.