PHYSICAL ASSESSMENT

a. General Survey

b. Measurements (Height, Weight, BMI, Vital signs)

Assessment Body Part Norms Actual Findings Analysis and

Method Used (Chepalo- Interpretation
Caudal)
Inspection Height N/A 160 cm/62 inches
Inspection Weight Normal Weight: Weight before
25 – 35 pounds pregnancy: 62
kg/136 lbs

Weight after
pregnancy: 71
kg/156 lbs
Inspection Body mass 18.5 – 24.9 23.2 A BMI of 23.2, height of
index (BMI) 160 cm and weight of
156 lbs are in the
normal range.
inspection Respiratory rate 8 – 24 breaths 22 breaths per The normal respiratory
per minute minute rate of a pregnant
woman is 8 – 24 breaths
per minute from first,
second and third
trimester.
Inspection Pulse rate 70 – 90 beats 86 – 88 beats per By the end of the third
per minute minute semester, the heart
(pregnant pumps from 40% to 90%
woman) more blood than before
pregnancy and the
resting heart rate
increases in 86 – 90
bpm.
Inspection Blood Pressure 94.8 to 143.5 120/76 mmHg 140/90 mmHg or high in
mmHg for pregnancy is usually
Systolic BP defined as high blood or
(pregnant hypertension and 90/60
woman) mmHg or less in
55.5 to 94.7 pregnancy is usually
mmHg for defined as low blood
Diastolic BP pressure or
(pregnant hypotension,
woman)
Inspect color Breast Color varies The texture of the The physical
and texture. depending on clients breast is examination should
the client’s skin smooth with no assess for systemic
 tone. Texture is edema. causes of edema, such
smooth, with no as heart failure (e.g.,
edema. Linear jugular venous
stretch marks distention, crackles),
may be seen renal disease (e.g.,
during and after proteinuria, oliguria),
pregnancy or hepatic disease (e.g.,
with significant jaundice, ascites,
weight gain or asterixis), or thyroid
loss. disease (e.g.,
exophthalmos, tremor,
weight loss). Edema
should also be
evaluated for pitting,
tenderness, and skin
changes.

Reference:

Edema: Diagnosis and

Management

KATHRYN P. TRAYES,
MD, and JAMES S.
STUDDIFORD, MD,
Thomas Jefferson (July
2013)

https://www.aafp.org/a
fp/2013/0715/p102.ht
ml

Inspect Breast Veins radiate The clients breasts During pregnancy, the
superficial either veins are vertically breasts may become
venous horizontally and with a lateral flare enlarged, which causes
pattern. toward the (longitudinal) the veins to
axilla which is normal. appear more
(transverse) or prominent.
vertically with a
lateral flare Reference:
(longitudinal).
Veins are more 5 causes of veins on the
prominent breasts Medically
 during reviewed by Debra Rose
pregnancy. Wilson, Ph.D., MSN,
R.N., IBCLC, AHN-BC,
CHT — Written by Zawn
Villines on February 25,
2020
https://www.medicalne
wstoday.com/articles/v
eins-on-breast

Inspect for Breast The breasts The client’s breasts

retraction and should rise is rise Unlike inverted nipples
dimpling. symmetrically, symmetrically, with which pull inward,
with no sign of no sign of dimpling retracted nipples lie flat
dimpling or or retraction. against the areola. They
retraction. don’t appear erect.
Retracted nipples can
become erect with
manual or
environmental
stimulation, such as
being touched, suckled,
or feeling cold. Your
doctor will note your
medical history and do a
physical exam of your
nipples and breasts.
They may also order a
diagnostic mammogram
and sonogram to get
images of the breasts
and nipples. These
images can help your
doctor determine the
root cause of your
condition. You may also
need an MRI.

Reference:

What Causes Nipple

Retraction and Is It
Treatable? Medically
reviewed by Valinda
Riggins Nwadike, MD,
 MPH — Written
by Corey Whelan on
March 28, 2019
https://www.healthline.
com/health/nipple-
retraction

Palpate for Breast No masses There’s no masses A complete clinical

masses. should be palpated in the breast examination
palpated. client breasts. (CBE) includes an
However, a firm assessment of both
inframammary breasts and the chest,
transverse ridge axillae, and regional
may normally lymphatics. In
be palpated at premenopausal women,
the lower base the CBE is best done the
of the breasts. week following menses,
when breast tissue is
least engorged. With
the patient in an upright
position, the physician
visually inspects the
breasts, noting
asymmetry, nipple
discharge, obvious
masses, and skin
changes, such as
dimpling, inflammation,
rashes, and unilateral
nipple retraction or
inversion.

Reference:

Evaluation of Palpable
Breast Masses

SUSAN KLEIN, M.D.

(May 2005)
https://www.aafp.org/a
fp/2005/0501/p1731.ht
ml
Inspect and Armpit No rash or The clients axillary A number of studies
palpate the infection noted. skin reports no concerning the analysis
axillae. rashes and of axillary odors have
infections upon assumed that the
inspection. characteristic odor
produced in the axillae
is due to volatile
steroids and isovaleric
acid. Organoleptic
evaluation of
Chromatographic
eluants from axillary
extracts was employed
to isolate the region in
the chromatogram
where the characteristic
odor eluted. The odor of
the dissolved eluant
was eliminated when it
was treated with base,
suggesting that acids
make up the
characteristic axillary
odor.

Reference:

Xiao -nong Zeng, James

J. Leyden, Henry J.
Lawley, Kiyohito
Sawano, Isao
Nohara & George Preti
(July 1991)
https://link.springer.co
m/article/10.1007/BF00
983777

Inspect and Breast No swelling, There are no Most breast lumps are
palpate the nodules, or presence of noncancerous, which
breasts, ulceration swelling, nodules means they are benign.
areolas, should be or ulceration on You might be surprised
nipples, and detected the patient’s to find a breast lump,
axillae. breast. but it’s important to
remember that it may
not affect your long-
term health. However, a
breast lump can be a
sign of cancer. It’s wise
to always seek a
medical evaluation of
any lumps or swelling
you discover on your
breasts. When you visit
your doctor to report a
breast lump, they will
probably ask you
questions about when
you discovered the
lump, and if you have
any other symptoms.
They will also perform a
physical exam of the
breasts.

Reference:

Breast Lump

Medically reviewed
by Valinda Riggins
Nwadike, MD,
MPH — Written by Ann
Pietrangelo — Updated
on August 14, 2019
https://www.healthline.
com/symptom/breast-
lump#What-to-Expect-
at-Your-Doctor-Visit-