Sacred

Heart College
College of Nursing

Alternative Related Learning Experience
BSN 2
POSTPARTUM CARE

POSTPARTUM ASSESSMENT

Patient’s Name: Jocelyn P. Latido Date of Birth: 12-02-2000 Age: 21 Gender:
Female
Address: Brgy. Mayao Crossing, Lucena City

Occupation: Unemployed Marital Status: Married Religion:

Roman
Catholic

VITAL SIGNS
BP: ___120/80__mmHg CR: ___90___bpm RR: __18____breaths/min Temp: ____37.1______°C

GENERAL APPEARANCE
Mrs. Latido’s general appearance is healthy
• Symmetry – Her face and body are symmetrical
• Old/age – Looks are appropriate to her age
• Mental acuity – She is alert and oriented to time, place and people
• Expression – She looks happy in her life, especially now that there is a new member in their family
• Trunk – She is fit and in good spirits
• Extremities – No physical deformities
• Appearance – Clean and well-groomed in appearance
• Movement – Has a good posture and steady gait
• Speech – Her speech is clear and her hearing is normal

BREAST:
• Appear normal and asymmetrical
• Engorged and lactating
• No redness, tenderness, streaking, or masses palpable in the breast tissue
• Areola appears to have suck marks and cracks
• Right Nipple is inverted
• With soreness

UTERUS:
• Firm and contracted
• Fundal check is without significant findings: involution is proceeding normally
BLADDER:
• Has a full bladder and experiences frequent urination
• Urinated every 2 to 3 hours
• Urine is yellow in color
• No pain or difficulty when voiding

BOWEL:
• Active and normal bowel sounds are heard upon auscultation
• Had spontaneous bowel movement
• Stool is dark and formed

LOCHIA:
• Red in color
• Moderate amount of lochia
• Temporary increase while breastfeeding
• Fleshy odor
• No infection noted

EPISIOTOMY:
• Mild edema and redness
• Slight bruising
• No drainage or discharges noted

HOMAN’S SIGN:
• No pain or tenderness in her cuff (leg)
• Homan’s sign negative

EMOTIONAL STATUS:
• Looks interested in caring for her infant
• Interested in learning about caring for her baby and herself
• Happy and Excited


Intactness and Presence of Drainage: _________________________________________________________________________

/
Lochia Discharge: # of Postpartum Day ____0 day (5 hours) Color: Rubra Serosa Alba

Fleshy Odor
Odor: ____________________________________________ Moderate
Amount: ________________________________________

Nichole John I. Culla 12-15-2021
NAME OF STUDENT ______________________________________________ DATE:_______________ SCORE:________/20
BSN – 2A Ma’am Joy Magsaysay
YEAR LEVEL/SECTION:______________________________ CLINICAL INSTRUCTOR: _____________________________

SIGNATURE OF CI: ______________________________

REMARKS: