SYSTEM ASSESSMENT

I. Central Nervous System

 Alert, conscious and coherent

 Awake and quick to respond to stimuli

 Partly attentive due to labor pains

 Able to comprehend what has been said and capable to participate

 Able to speak local, dialect fluently

II. Respiratory System

 respiratory distress noted

 Resonant breathing sounds are constant and normal

 Tachypnea or shortness of breath

 RR: 22 cpm

III. Musculo-Skeletal System

 Upon inspecting her arm, thigh and calf were equal in size on both sides

of the body.

 Full range upper extremities but difficult to flex her hips due to increase

abdominal mass or enlarge uterus

 Client is able to ambulate but with assistance.

IV. Reproductive System

 Lochia trans abdominal vertical surgical incision. Hemorrhoids Bruised

or swollen vagina

 Breast are engorged apply warm packs and express milk

V. Gastro-intestinal System
  Active bowel sound in all quadrants

 Stools are dry and separate hard lumps, like nuts, hard to pass

VI. Genito-urinary System

 Pubic hair is evenly distributed.

 Dark colored vagina

 Urine color is amber yellow in the amount of approximately 30cc per hour

VII. Circulatory Sytem

 BP 140/80mmHg

 HR of 28cpm

 Blood type: O

 Temperature 36.8ᵒ C

 Strong with pulse rate of 105bpm

VIII. Integumentary System

 Presence of linea negra and striaegravidarum at the abdomen

 Hair is shiny, soft and smooth. No infestations of parasites are noted.

 Nails has pink tones

 The color of the skin is brown.

 Surgical incision in the abdomen present