PHYSICAL ASSESSMENT

Case Scenario: Miss Te is a 24 year old G2P2. She delivered a term live-baby girl via
normal spontaneous vaginal delivery, with mediolateral episiotomy. She had estimated
250cc blood loss right after delivery. Immediately after delivery, the vital signs were taken:
BP = 110/70 mmHg, PR = 88 bpm, RR = 22 cpm and Temp = 36.5 ͦ C. She chose to do
breastfeeding.
In the endorsement, the previous shift noted that she has not voided yet after 8 hours of
delivery. There was minimal bloody discharge. Uterine was kept contracted. Ongoing IVF
of the patient was #2 D5LR 1L+10 units oxytocin at 120cc/hr to be consumed and
discontinued.
During the morning rounds, Miss Te told the nurse, “Ma’am, sakit po ang dibdib ko. Ang
left nipple ko po ay namaga. Itigil ko po ba ang pagpapasuso, Ma’am?” The nurse noted
there was engorged breast.

General Assessment:
Patient is a 24 year old G2P2 who recently delivered a term live-baby girl via NSVD. A
mediolateral episiotomy was performed to aid delivery and patient has a repaired 2nd
degree vaginal tear. She has not voided 8 hours after delivery. IV line is patent, and
infusion is to be consumed and discontinued. She is breastfeeding. Patient’s mannerisms
and verbalizations suggest she was anxious. All vital signs were within normal range,
except for the respiratory rate right after delivery, which was slightly elevated, but
elevation is expected after strenuous procedures.

Vital Signs:
Blood pressure manually taken at left arm while sitting, recorded at 110/70 mmHg.
Temperature taken using infrared thermometer at left temporal area, recorded at 36.7 ͦ C.
Pulse taken at right radial artery, recorded at 85 beats per minute. Respiratory rate at 20
cycles per minute, with bilateral chest expansion.

Further Physical Assessment:

Skin: Patient has a fair complexion and has presence of melasma on her face and chin.
Generally, skin is warm to touch. No sign of tenderness, lesions, edema, and with good
skin turgor. There is presence of striae gravidarum and linea nigra at the abdomen.
Temperature is 36.7 ͦ C.
Thorax and Lungs: The chest wall is intact with no tenderness and masses. There is full
and symmetric expansion. The client manifested quiet, rhythmic, and effortless
respirations. The spine is vertically aligned. There were no visible pulsations on the aortic
and pulmonic areas. There is no presence of heaves or lifts. Patient verbalized feeling
pain in her chest area.
Abdomen: Faint stretch marks (striae gravidarum) and the linea nigra is visible during
inspection. No lesions, scars, and rashes are present on the skin of the abdomen. Bowel
sounds are normal. Fundus palpated approximately 1cm below umbilicus. Bladder is
slightly distended upon palpation.
Breast and Axilla: The patient's breasts are fair, slightly unequal in size and is
asymmetrical. Nipples are rounded, everted, erected, same size and equal in color.
Nipples were smooth. There is a presence of sensitivity and tenderness. The breast
seems to be firm, engorged, and heavier, as observed by patient. Patient verbalized pain
in her chest area. There were no lesions, masses, nodules, dimpling, and bloody
discharge. Veins were slightly visible.
Genito-urinary: The external genitalia have an equal hair distribution, and the skin is
intact—the 2nd degree vaginal tear was repaired and the mediolateral episiotomy was
properly sutured. Upon assessment of episiotomy, no redness, edema, ecchymosis, and
discharge, and wound edges were closed. No sign of hardened areas, hematomas, and
infection. Approximately 100cc of slightly dark bloody discharge (lochia rubra) noted 8
hours after delivery, with no blood clots present. Discharge is odorless. Patient has only
changed her sanitary pad once. Patient has not urinated or voided since having delivered
8 hours ago. She has not felt the urge to urinate or defecate upon questioning. She feels
no pain, except for feeling bruised around her perineal area.
Extremities: Upper and lower extremities are noted to be symmetrical in size, color, and
temperature. Slight non-pitting edema was present on the client’s feet. The muscles are
not palpable with the absence of tremors. They are normally firm and showed smooth,
coordinated movements. There were no presence of bone deformities, tenderness and
swelling. There were no swelling, tenderness and joints move smoothly. Negative for
Homan’s sign.
BUBBLE-HE
Breast: The patient's breasts are fair, slightly unequal in size and is asymmetrical.
Nipples are rounded, everted, erected, same size and equal in color. Nipples were
smooth. There is a presence of sensitivity and tenderness. The breast seems to be firm,
engorged, and heavier, as observed by patient. Patient verbalized pain in her chest area.
There were no lesions, masses, nodules, dimpling, and bloody discharge. Veins were
slightly visible.
Uterine Fundus: Fundus palpated approximately 1cm below umbilicus. Bladder is
slightly distended upon palpation. It is palpated to have regular size and shape, is firm,
mobile, in the midline, and nontender.
Bladder Function: Patient has not urinated or voided since having delivered 8 hours
ago. She has not felt the urge to urinate upon questioning. She was not catheterized
during labor and delivery.
Bowel Function: Patient has not voided since delivery. Patient has also not felt the urge
to defecate upon questioning.
Lochia: Approximately 100cc of slightly dark bloody discharge (lochia rubra) noted 8
hours after delivery, with no blood clots present. Discharge is odorless. Patient has only
changed her sanitary pad once.
Episiotomy (Perineum): The 2nd degree vaginal tear was repaired and the mediolateral
episiotomy was properly sutured. Upon assessment of episiotomy, no redness, edema,
ecchymosis, and discharge, and wound edges were closed.
Homan’s Sign (Legs): Lower extremities are noted to be symmetrical in size, color, and
temperature. Slight non-pitting edema was present on the client’s feet. The muscles are
not palpable with the absence of tremors. They are normally firm and showed smooth,
coordinated movements. There were no presence of bone deformities, tenderness and
swelling. There were no swelling, tenderness and joints move smoothly. Negative for
Homan’s sign.
Emotions: Mother is able to rest and has enough energy to breastfeed her baby and talk
to her husband. Comfort level, from a scale of 1-10, was 7 according to client, mostly
comfortable but had slight backache from being in bed for an extended period of time and
because of recent delivery. Anxiety level from 1-10, according to the facial anxiety scale,
was 4 (mild-moderate) when she asked about breast engorgement. She was worried
about continuing breastfeeding. She has a decreased appetite and thirst; she did not
finish her latest meal and has only consumed 250 mL of water since delivery. She is very
attentive with her newborn and feels calmer and reassured when she is holding her. Her
husband is with her to assist her, bringing her things, and supporting her during
breastfeeding. Her other child is currently at home, being watched over by her sister (the
child’s aunt).