POST-ASSESSMENT Pathophysiological basis

PSYCHOSOCIAL
General Appearance  Patient is seen to have a rough
time, she is weakening in look
due to the pain that she
experiences, and restless. In the 2nd assessment

• Patient is also noticed to have It is due to the incision soreness

facial grimace and moaning as she that she felt.
complains of pain on her incision
site.

• Guarding behavior on the

abdomen particularly on the
incision area.
Affect • The patient is seen to be In the 2nd assessment
restless and irritable.
It is due to the sharp shooting
pains that the client feels in her
incision area.

Orientation  Patient is well oriented of date, In the 2nd assessment

time, and place.
Client is still aware

Memory  Intact she is well- conscious In the 2nd assessment

Client is still alert in that present

time.

Speech  The patient was able to talk In the 2nd assessment

back but in a low speech, but it
is still audible.
Non-verbal Behavior  The patient is seen to have a
facial grimace and does moan.
Client can still response.
In the 2nd assessment
It is the way the client response
to her pain that she felt in the
incision area.

POST-ASSESSMENT
 ELIMINATION
Stool In the 2nd assessment

• Frequency • After 24 hours of being Most women poop within 24 hours of

admitted in the OB ward having a vaginal delivery and within three
the patient was not able days after a C-section.
to stool.
• Consistency
 According to the client Passing gas is one of the earliest signs
• Color the patient had that a person's bowels are back to
already passed flatus functioning normally.
Urine In the 2nd assessment
The patient has an
• Frequency indwelling catheter which The Client urine output is normal.
• Color is monitored on an hourly
• Odor basis: color of pale
• Clarity yellow, has no foul odor,
and is clear.

• Amount: 39 cc per hour

Lochia The client reported a In the 2nd assessment
reddish discharge (rubra).
Blood will be a dark or bright red and will
She reported one soaked be very heavy. It is normal to see clots in
pad is used every 1-2 your lochia during this stage.
hours.
Breast  Since both breasts In the 2nd assessment
are used in
breastfeeding, The assessment of breast of the mother
both are normal: is normal and client was able to breast
soft or filling. feed her baby.

 no cracking or
bleeding
 nipples erect with
stimulation
 colostrum present
(milk) and no
redness
Prominent striae In the 2nd assessment
Abdomen gravidarum and Linea Stretch marks usually become
nigra considerably less noticeable about six to
12 months after childbirth.
 • Minor bleeding on
the surgical incision but
no discharge such as pus.
Wound area not
edematous and also, no
redness.
• Pain of 8/10 on the area
of incision.
Uterus • Upon palpation it is
firm.
Bladder  Patient has no signs of
bladder injury.
Fetal Heart Tone Awake- 138 bpm
Asleep- 120 bpm
Bowel Sound soft and nondistended,
normal bowel sounds in
all quads, no difficulty in
bowl movements.
Toilet Activity The patient can walk
slowly and needs
assistance in going to the
bathroom.
For 1 or 2 weeks after the C-section, a
woman may also notice some periodic,
minor bleeding from the incision site.
The incision area is normal no signs of
wound infection.
In the 2nd assessment
It is normal
In the 2nd assessment
It is normal
In the 2nd assessment
The fetal heart tone is in the normal
range.
In the 2nd assessment
Assessment in the bowel sound is normal
no sign of bowel problems.
In the 2nd assessment
Since client is still weak, she needs a
support escort in walking and walking
will help the client relieve gas pains, have
a bowel movement and improve urine
output.

POST-ASSESSMENT

REST AND ACTIVITY

Current activity • Can sit, stand, and walk In the 2nd assessment
but slowly and with
assistance. It is due to her incision and pain that she
felt.
Activity intolerance • The client cannot move In the 2nd assessment
in a normal speed. She
needs assistance when Client is still in recovery process, but
ambulating. walking is very recommended.
ADL’s Grooming: patient can In the 2nd assessment
wash her own face and
 can The client movement and activities is
comb her hair limited to some because she is recovering
independently. to her incision and client should not lift
anything heavier than her baby.
•Feeding: Patient was
able to feed herself
without the assistance of
the others.

•Ambulating: can move

in a slow rate and with
assistance

•Dressing: needs
assistance

•Communicating: Patient
talks in low pitch and
responds more through
nodding of the head.
Sleep Quality of sleep is In the 2nd assessment
shallow since she cannot
• Duration sleep well due to pain. The client is having difficult in sleeping
• Quality because she is still adjusting on the pain
• Pattern • She is also easily that she experiencing and her new added
awakened and total job to look out for the newborn.
sleeping hour is 4-5
hours in a day since she
breastfeeds every two
hours.
Body frame Mesomorph In the 2nd assessment

The client have a normal body type.

Gait The client was able to In the 2nd assessment

walk one step at a time
but in a slow rate. It due to her pain that she experiencing.
Coordination Patient is well In the 2nd assessment
coordinated.
The coordination of the client is normal
Balance Patient can stand but not In the 2nd assessment
well due to the pain
It is due to her incision
Muscle strength and Muscle strength of both In the 2nd assessment
tone upper and lower
extremities is 3/5.
Normal muscle tone.
Range of Motion Arms
• Can extend arms, can
abduct and adduct, and
can-do pronation and
supination of arms.
It is due to her incision that gives her
weakness and lack of strength.
A C-section is a major surgery, and it can
change a person's body and especially
their core muscles in drastic ways
In the 2nd assessment
Some of the client Range of motion is
limited due to abdominal surgery and
assistance to the client is still needed.

Elbows
• Full resistance on both
elbows.

Wrists
• The client is able to
bend down and back
both wrists.

Hands and fingers

• The client is able to
move both hands and
fingers. Can do close and
open.

Knee
• The client can bend,
extend or flex left and
right knee but with slight
to moderate assistance.
Mobility/Use of Patient uses walker. In the 2nd assessment
assistive devices
For support and care of the client.

POST-ASSESSMENT

SAFE ENVIRONMENT
Allergies In the 2nd assessment
The patient is not allergic The client shows no allergic reactions
on medications. on medications.
 The patient is not allergic The client doesn’t have allergies when it
on foods. comes to foods

The patient is not allergic The client stay in hospital shows no

on environment.
SENSES
Eyes/Vision
PERRLA Pupils, Equal
, Round, Reactive (to),
Light, Accommodation.
allergies.
In the 2nd assessment
Vision is normal and good. The client
can clearly see the objects.

Equal: pupils are equal in

shape and size.

Round: pupils are round

Reactive to light and

accommodation: pupils
get smaller in bright or
direct light, as well as
when a person focuses on
something very close to
their eyes.

Hearing The client stated that she In the 2nd assessment

doesn’t not use hearing
aid because her hearings The hearing ability of the patient is
are normal functioning normally and can response.

The patient have a

normal voice and audible

Able to comply in
counting 6,7,8.9

The hearing ability of the

patient and response are
indicated normal
Taste The patient taste bud is In the 2nd assessment
normal because she was
able to differentiate the The sense of taste of the client is
different types of taste. indicated normal.

Smell No problem noted in each In the 2nd assessment

nostril and patient was
 able to sniff and smell. The sense of smell of the client
indicated normal as she can distinguish
different odors.
Skin integrity In the 2nd assessment

There is no pallor, no The skin of integrity of the client show

edema, no presence of health because there is no sign of any
lesions, and no erythema. skin problem or infection.

Mucous membranes Mouth: lips are normally In the 2nd assessment

symmetrical, pink,
smooth, and moist. Client mucous membrane assessment is
indicated normal.
No indications of
dehydration.

Temperature 36. 8 degrees Celsius In the 2nd assessment

(Right axillary)
The client temperature is in the normal
range.

POST-ASSESSMENT

OXYGENATION
Pulse oximetry 95% In the 2nd assessment

A normal level of oxygen is usually 95% or

higher.

Respiration In the 2nd assessment

• Rate 17 counts per minute
The normal respiration rate for an adult at
• Rhythm Regular rest is 12 to 20 breaths per minute.

• Character The amount of air

inhaled and exhaled
with each breath is in
the normal range.

Depth is normal. The

inspiration volume and
depth of breast
 movements are
maintained, with equal
expansion and
symmetry.
Lung sounds Loud, high-pitched In the 2nd assessment
bronchial breath sounds
over the trachea. The chest wall is symmetric, without
Medium pitched deformity, and is atraumatic in
bronchovesicular sounds appearance. No tenderness is
over the mainstream appreciated upon palpation of the chest
bronchi, between the wall. The patient does not exhibit signs
scapulae, and below the of respiratory distress.
clavicles. Soft, breezy,
low-pitched vesicular
breath sounds over
most of the peripheral
lung fields.

The patient does not

exhibit signs of
respiratory distress.
Nails Nails: Pink tones are In the 2nd assessment
seen in the nails
The client nails of both and feet are seen
to be healthy.

Capillary Refill The Capillary beds refill In the 2nd assessment

in 1-2 seconds which is
normal. The time taken for a distal capillary bed
to regain its color after pressure is normal
Pink tone returns it is indicated that client is not
immediately to blanched dehydrated.
nail beds when pressure
is released

Peripheral pulses Rhythm: regular In the 2nd assessment

between intervals
The mother has a normal peripheral
Location: Radial pulse pulse assessment.

Rate: 70 A normal pulse rate after a period of rest

is between 60 and 80 beats per minute
Strength: normal (bpm).
Blood pressure 120/80 mmHg In the 2nd assessment

The client blood pressure reading is in

the normal range.

Edema No present of Edema In the 2nd assessment

The client has no signs of abnormal

accumulation of fluid in certain tissues
within her body.
Homan’s sign Negative In the 2nd assessment

Negative Homans' sign doesn't rule it

out.

NUTRITION
Hospital Diet/restriction In the 2nd assessment
Gradual intake of
soft/light meals Good nutrition is needed to speed healing
with protein after your cesarean section (C-section) and
give you needed energy.

Body needs protein to help build and

repair muscle, skin, and other body
tissues. Protein also helps fight infection,
balance body fluids, and carry oxygen
through your body.

Fluid intake The client was In the 2nd assessment

advised to have a
fluid intake of 800- To compensate for the extra water that is
1000ml per day as used to make milk. One way to help you get
tolerated. the fluids you need is to drink a large glass
of water each time you breastfeed your
baby.

Intravenous fluid In the 2nd assessment

• Site  Right
• Solution metacarpal The solution is a parenteral fluid and
 PNSS 1L to electrolyte replenisher.
run for 8
Hours
Height and weight She weighs 55 kg. In the 2nd assessment
 5feet and 3 inches Most women lose around 13 pounds (6 kg)
or 5.25 foot right after childbirth, which includes the
(1.6002m) baby's weight, as well as the weight of the
amniotic fluid and placenta.

BMI Her current BMI is In the 2nd assessment

21.47
It is indicated normal
Skin turgor As we pinch the In the 2nd assessment
clients
skin turgor goes It is indicated that the client is not
back immediately dehydrated.
to its original state
after pinching and
there is no
occurrence of skin
lesion
Ability to: In the 2nd assessment
• Chew The Patient is able
• Swallow to bite and chew. The client shows no difficulties when
• Feed self The patient can incomes in chewing, swallowing, and
swallow and digest. feeding.
The patient is
independent in
feeding herself.