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  • 16IV. PHYSICAL ASSESSMENT Area to be assessed Normal findings Actual findings Analysis 1. General AppearanceMood and affect Appropriate to She’s cooperative She’s slightly situation/ cooperation upon the assessment recoveredSigns and distress No distress noted Slightly distress Due to after pain’s of pregnancyPosture Relaxed erect posture The patient is relaxed NORMALBody movement Coordinated Able to do NORMAL movement coordinated movementsHygiene and grooming Clean and neat She is clean, she Able to practice bathes her body but hygiene. With not with her head to limitations on her be rinsed with water prestigious beliefsType of clothing Clean and The client has clean Able to practice presentable clothing and presentable good clotting clothing 2. MeasurementsHeight 5’4’’Weight 54 kgBMI 18.5-24.9 21.09 NORMAL 3. Vital signsTemperature 36.5⁰C-37.5⁰C 36.9⁰C NORMALPulse rate 60-100 bpm 75 bpm NORMALRespiratory rate 12-20 cpm 20 cpm NORMALBlood pressure 100-140/60-90 110/80 mmHg NORMAL mmHg 4. Cephalocaudal assessment Skin Inspection: -varies from light to -the skin of the Increase in melanin, brown, from ruddy patient varies from increase the level of pink to light; from light to brown melanocyte - yellow over tones to because of the stimulating olive increased in melanin hormone. -generally uniform production. except in areas Hyper pigmentation exposed to sun results from -pigmentation( hormonal influence. palms, lips, nail beds) I dark skinned Source: health person -pinkish palms, assessment 4th -no edema pinkish nail beds edition by Wolter -freckles, some -no edema Kluwers page 611. birthmarks, some flat -some birthmarks, and raised nevi, no some flat and raised abrasions or other nevi, no abrasions or lesions other lesions -note for hyperpigmented
  • 17 areas associated with -a little bit moisture pregnancy NORMAL Palpation: -the temperature is - moisture in skin normal folds and axillaries -the temperature is -when the skin of the uniform within patient is pinched the normal range skin springs back to -when pinched, skin previous state. springs back to previous state NORMAL Nails Inspection: - nails during -the nails of the client NORMAL pregnancy tends to is 160⁰ angle increase in growth, softening and -highly vascular Softening and thinning are common thinning of the nails -convex curvature, during pregnancy angles of nails is are normal by the 6th about 160⁰ week of gestation. -highly vascular and Source: Wolter pink in light skinned Kluwers page 611 clients: dark skinned clients may have -smoothly brown or black -prompt return to pigmentation in usual color longitudinal steaks Palpation: -smooth texture -prompt return for usual color( Blanch NORMAL test) Eyes Inspection: -examine cornea, -there is no lesions NORMAL lens, iris, pupil, lens and inflammation -external eye structure should be -the eyes blink Narrowing of from lesions and arterioles or AV inflammation micking may -a blink should be indicate present hypertension. Source: Wolter Kluwers page 625Eyebrows Inspection: -hair evenly -the hair evenly NORMAL distributed; skin distributed and skin intact is intact -eyebrows -symmetrically symmetrically aligned and equally aligned; equal move movementEyelashes Inspection: -Hair is evenly -hair is evenly NORMAL distributed; distributed and curled -slightly curled slightly outward outward Eyelids Inspection:
  • 18 -skin intact; no -skin is intact, no NORMAL discharge; no discharge and no discoloration discoloration -lids close -lids close symmetrically symmetrically -approximately 15-20 -16 blinks per blinks per minute; minute; bilaterally bilateral blinking blinking -when lids open, no -no sclera above sclera above corneas, corneas, and and upper and lower upper/lower boarders borders of cornea are of cornea are slightly slightly covered covered -no ptosis -no ptosisConjunctiva(bulbar) Inspection: -transparent; -transparent, NORMAL capillaries sometimes capillaries sometimes evident; sclera evident appears white -sclera is whitePalpebral conjunctiva Inspection: -moist -moist NORMAL -no foreign objects -no foreign objects -shinny, smooth and -shiny,smooth & pink pink or red Sclera Inspection: -sclera appear white -white NORMAL -no yellowish -no yellowish discoloration discoloration -some capillaries are -some capillaries are visible visible Cornea Inspection: -transparent, shinny -transparent, shinny NORMAL and smooth; details and smooth; details of iris are visible of iris are visible -client blinks when -client blinks when cornea is touched, cornea is touched indicating that the trigeminal nerve is intact Iris Inspection: -proportional to the -the iris is NORMAL size of the eye, proportional to the round, black or size of the eyes, brown and round and black and symmetrical symmetrical; the iris -the anterior chamber is transparent of the iris is transparent Pupils Inspection: -black in color, equal -the pupils are black, NORMAL in size, normally 3-7 equal in size, round, mm in diameter, smooth border, iris is round, smooth flat and round. border, iris is flat and -pupils equally round round. reactive to light accomodation
  • 19 Visual Acuity Inspection: -able to read -able to read newsprint newsprint NORMAL -20/20 vision on snellen chart Pupils Reaction and Inspection: Accomodation -pupils constrict -the pupils constrict NORMAL when looking at near when looking at near objects, pupils dilate objects when looking at far -pupils dilate when objects, pupils looking at far objects coverage when near -pupils coverage object is moved when near object is towards the nose. move towards the nose.Lacrimal Gland, Lacrimal Inspection and Sac and nasolacrimal Palpation: Gland -no edema or -no edema or NORMAL tenderness over tenderness over lacrimal gland lacrimal gland -no edema or tearing -no edema or tearing on lacrimal sac and on lacrimal sac and nasolacrimal duct. nasolacrimal duct. Exrta ocular Muscles Inspection: -both eye -both eyes NORMAL coordinated, move in coordinated and unison with parallel move in unison with alignment parallel alignment. Visual Fields Inspection: -When looking -when looking NORMAL straight ahead, client straight ahead, client can see objects in her can see objects in periphery her periphery Ears Auricles Inspection: -color same in facial -sane color in facial NORMAL skin skin -symmetrical position -symmetrical position Pregnant woman -auricle aligned with -auricle aligned with may report a outer canthus of the outer canthus of the decreased in eye ,about 10 degrees eye about 10 degrees hearing, a sense of from vertical from vertical fullness in the ear or earaches because of the increased in the vascularity of tymphanic membrane and blockage of Eustachian tubes. Source: Wolter Kluwers page 611 External ear canal Inspection: -distal third contains -distal third contains NORMAL hair follicles and hair follicles and
  • 20 glands gland -dry cerumen -dry cerumen -pearly gray color, -pearly gray and semi semi transparent transparent -no skin lesions -no skin lesionsHearing Acuity Assesment: -normal voice tone -normal voice tone NORMAL are audible are audible -able to repeat non -able to repeat non consecutive numbers consecutive numbers -able to hear scratch -able to hear scratch ticking in both ears ticking in both ears Nose Inspection: -symmetrical and -symmetrical and NORMAL straight straight -midline -midline Nasal mucosal -no discharge or -no discharge or swelling and flaring flaring redness may result -uniform -uniform from increased in -mucosa is pink -mucosa is pink estrogen production. -clear, watery Epistaxis is discharge -no lesion common variation Palpation: -nasal septum intact because of increased -no lesion in the midline in the vascularity -nasal septum intact - air moves freely as supply to the nares in the midline the client breaths during pregnancy. -for consistency of through the nares Source: both nasal cavity, air -no tenderness Wolter Kluwers moves freely as the page 625 client breaths through the nares -no tenderness Sinuses Percussion: -no tenderness, -no tenderness, NORMAL masses and edema masses and edema Mouth Inspection and Lips palpation: -uniform pink color -uniform pink color NORMAL -soft, moist and -soft, moist and smooth texture smooth texture -symmetrical in -symmetrical in appearance and appearance and movement movement -ability to purse lips -able to purse lips -no edema -no edemaBuccal mucosa Inspection and palpation: - uniform pink color - uniform pink color NORMAL -moist, smooth, soft, -moist, smooth, soft, glistening elastic glistening elastic texture texture Teeth Inspection: -32 adult teeth -complete teeth with Due to calcium
  • 21 -smooth, shiny white some dental carries needs of the fetus enamel the mother usually -smooth, intact have dental carries dentures Gums Inspection and palpation: -pink gums -pink gums NORMAL -moist, firm texture -moist, firm texture Gingival bleeding to gums to gums when brushing the -no retraction of -no retraction of teeth and gums gums hypertrophy are common. Epulis which are small irritating nodules of the gums developed. Nodules resolved on their own. Source: Wolter Kluwers page 611Tongue/ floor of the Inspection and mouth palpation: -central position -central position NORMAL -pink color -pink color -smooth lateral -smooth lateral margins; no lesions margins; no lesions -raised papillae -raised papillae -moves freely, no -moves freely, no tenderness tenderness -frenulum is at the -frenulum is at the midline, straight and midline, straight and thin thin -smooth tongue base -smooth tongue base with prominent veins with prominent veins Palates Inspection and palpation: -light pink, smooth, -light pink, smooth, NORMAL soft palate soft palate Uvula Inspection: -positioned in -positioned in NORMAL midline of soft palate midline of soft palate -pink in color -pink in color Oropharynx Tonsils Inspection and palpation: -pink and smooth -pink and smooth NORMAL posterior wall posterior wall -no discharge -no discharge -of normal size: -of normal size: -Grade 1- tonsils are -Grade 1- tonsils are behind the tonsilar behind the tonsilar pillar pillar -Grade 2- tonsils are between the tonsils and uvula -Grade 3- tonsils touch the uvula -Grade 4- one or both
  • 22 tonsils extended to the midline of the oropharynx -gag reflex is present -gag reflex is present Neck Inspection and palpation: -Muscles equal in -Muscles equal in Increase in level of size; head centered size; head centered melanocytes -coordinated, smooth -coordinated, smooth stimulating movement with no movement with no hormone. discomfort discomfort -head flexes 45⁰ -head flexes 45⁰ -head hyperextends -head hyperextends 60⁰ 60⁰ -head laterally rotates -head laterally rotates 70⁰ 70⁰ -has a pigmentation of dark brown to black in color at her neck. Lymph nodes Palpation: -no tenderness -no tenderness NORMAL -not palpable -not palpable Trachea Inspection: -central midline of -central midline of NORMAL neck, spaces are neck, spaces are equal in both sizes equal in both sizes Thyroid Palpation: -isthmus may be -isthmus may be NORMAL visible in thin neck visible in thin neck -no nodules -no nodules ThoraxPosterior thorax Inspection: -anteroposterior to -anteroposterior to NORMAL transverse diameter transverse diameter in ratio of 1:2 in ratio of 1:2 -chest symmetry (36cm:18cm) -spine vertically -chest symmetry aligned -spine vertically -(lateral deviation) aligned spinal column, right -(lateral deviation) and left shoulders spinal column, right and hip at the same and left shoulders height and hip at the same NORMAL Palpation: height -skin intact; uniform temperature -skin intact; uniform -chest wall intact; no temperature masses , no -chest wall intact; no tenderness masses , no -full and symmetric tenderness chest expansion -full and symmetric -bilateral symmetry chest expansion of vocal fremitus -bilateral symmetry NORMAL -higher pitched voice of vocal fremitus Percussion: -higher pitched voice
  • 23-resonate, exceptover scapula -resonate, except-lower point of over scapularesonance is at the -lower point ofdiaphragm resonance is at the-diaphragmatic diaphragmexcursion, excursion -1.5 inchesis 3-5 cm (1 ½ to 2in) bilaterally-diaphragm is usuallyslightly higher on the -diaphragm is usually NORMALright side slightly higher on theAuscultation: right side As the pregnancy-vesicular and progresses,bronchovesicular -vesicular and progesteronebreath sound bronchovesicular influences the breath sound relaxation of the ligaments and joints. Relaxation allows the rib cage to flare thus increasing the anteroposterior and transverse diameter. The accommodation is necessary as the pregnancy progresses and the enlarging uterus pushes up on the diaphragm. Client’s respiratory pattern change from abdominal to costal. Shortness of breath is a common complaint during the last trimester. Client maybe aware of her breathing pattern and deep respirations and more frequent sighing. Oxygen requirement increased with tidal volume increased by 30%-40%. All of these changes are normal and are these changes are normal and are expected during last trimester. Source: Wolter Kluwers page 612
  • 24Anterior thorax Inspection: -quiet, rhythmic and -quiet, rhythmic and NORMAL effortless respiration effortless respiration -costal angle is less -costal angle is less than 90⁰ and the ribs than 90⁰ and the ribs insert to spine at insert to spine at approximately 45⁰ approximately 45⁰ angle angle Palpation: -uniform -uniform NORMAL temperature, no temperature, no tenderness upon tenderness upon palpation and no palpation lesions Assessment: NORMAL -Full symmetric -Full symmetric excursion; thumbs excursion; thumbs normally separates 3- normally separates 5cm 3.5 cm Palpation: NORMAL -vocal fremitus is vocal fremitus is normally decreased normally decreased Trachea Percussion: -bronchial and -bronchial and NORMAL tubular sound tubular sound Thorax Percussion: -bronchovesicular -bronchovesicular NORMAL sounds between the sounds between the breast area and breast area and vesicular sound in the vesicular sound in the chest periphery chest peripheryVascular heart Inspection and palpation: -no auscultion, and although some people have aortic pulsation -no pulsation - no lift or heave -pulsation visible in 50% adults and palpable in PMI I n the fifth MCL -no lit or heave aortic pulsation at the base of the sternumCarotid arteries Palpation: -symmetric pulse -symmetric pulse NORMAL
  • 25 volumes; full volume: pulsations, thrusting - full pulsation, quality; quality thrusting quality, remains same when quality remains the client’s breath, turn same when clients head and changes breaths, turn head from sitting to supine and changes from sitting to supineHeadSkull Inspection: -Rounded and -Rounded and NORMAL symmetric with symmetric frontal, parietal and occipital prominences, smooth skull contour Palpation: -smooth, uniform, -Smooth, uniform consistency consistency; absence -no nodules and of nodules or masses massesScalp Inspection: -lighter than color of -lighter than the NORMAL the complexion complexion -can be moist and -moist oily No scars, nits, lice -no scars noted and dandruff -free from lice, nits and dandruff -no lesions -no lesions should be noted Palpation: -no tenderness -no tendernessHair Inspection: -evenly distributed -hair is distributed NORMAL hair -thin hair; fine -thick hair -silky; resilient hair Growth of hair -silky resilient hair -no infection increased during -no infection or -variable pregnancy hormone infestation -black and straight increased the -variable hair growing phases of -hair color may range the hair follicle and from pale, blond to transient hair loss is deep black, texture noticed and may be straight, commonly peaks at curly, kinky, fine or 3-4 post partum course normally resolved within 9month-1 year after the delivery. Source: Wolter Kluwers page 611
  • 26Face Inspection: -symmetric or -symmetric slightly asymmetric -palpebral fissures facial features; are equal in size palpebral tissues -symmetric nasolabia equal in size, -symmetric pulse symmetric volume nasolabial; -full pulsation Pigmentation on the symmetric pulse -has a pigmentation face or the volume; full on her face ranging Chloasma or mask pulsation thrusting from light to dark of pregnancy quality brownBreast Inspection: -Rounded shape, With tenderness and Due to increase slightly unequal in milk discharge level of estrogen size, generally and the release of symmetric hormone prolactin -skin uniform in and oxytocin. The color, same in milk is reserved at appearance the acinar cell, Palpation: where the lobule are -no tenderness or enlarged and milk masses, nodules or are deposited in nipple discharge here, tenderness occurs not unless the milk will be discharged when breastfeeding. Venous congestion is noted with prominence of veins , montgomery’s tubercles are prominent. Breast size increased and the nodular also increase. Colostrums is excreted, especially in the third trimester. Source: Wolter Kluwers` page 626Areola Inspection: -round or oval Shape is round and Due to lactation -color varies from the color is dark light pink to dark brown brown -irregular placement Palpation: There is nipple -No tenderness, discharge masses, nodules or nipple discharge
  • 27 Nipples Inspection: -round or overall -round Darken and -color varies -dark brown enlarged nipples -inversion of one or because it has an both nipples that is ampulla where the present from puberty reservoir of milk takes place when breast feeding. Because of elevated estrogen level that stimulates the melanocyte- stimulating hormone. Source: Wolter Kluwers page 611Sub clavicular and supra Palpation: Normal clavicutal Axillary. No -no tenderness, no tenderness, masses masses, no nodules Abdomen Inspection: -No tenderness -blemished skin Due to enlargement -uniform color -dark of the uterine cavity -maybe flat, rounded -rounded the abdomen was or scaphoid -stretch mark present stretched. -symmetric -no evidence of Stretch mark in movement caused by enlargement of liver related to the respiration and spleen stretching of the -umbilicus centrally skin of the abdomen located -symmetrical while the fetus is -no visible vascular growing, it affects pattern the elasticity of the skin, varies its color from crystal clear white marks. Auscultation: -you can hear bowel -you can hear bowel NORMAL sounds, absence of sounds, absence of arterial bruits and arterial bruits and friction rubs friction rubs Percussion: -there is tympanic -there is tympanic NORMAL sound over stomach sound over stomach and gas filled bowels, -no evidence of dullness, especially enlargement of the over the spleen and liver and spleen liver or a full bladder -symmetrical Palpation: -there is no -no tenderness NORMAL tenderness, relaxed -relaxed abdomen, abdomen with smooth smooth, consistent tensionMusculoskeletal system
  • 28 Muscles Inspection: NORMAL -equal size on both -equal size on both sides of the body sides of the body -no contractures -no contractures -no fasciculation or -no fasciculation or tremors tremors -normally firm -normally firm -smooth coordinated -smooth coordinated movements movements -equal strength on -equal strength on each side each side Bones Inspection: NORMAL -no deformities -no deformities Palpation: -no tenderness or -no tenderness or swelling swelling Joints Inspection and NORMAL Palpation: -no swelling -no swelling -no tenderness, -no tenderness, crepitation or nodules crepitation or nodules -joints move -joints move smoothly smoothly Axillaries Assessment: NORMAL -skin color is darker -color varies from than the normal color light brown to dark of pre pregnancy brown state. -no swelling -no swelling -no lesions -no tenderness, -no tenderness, nodules nodulesUpper and Lower Assessment: NORMAL extremities -be able to move -able to move joints joints without freely tenderness -range of motion varies in accordance with persons genetic make-up and degree of physical activity Genitalia Inspection: Assessment: -note for hair -presence of lochia After a vaginal distribution, color of -presence of odor birth, the vagina is skin, varicosities, and soft with few rugae scars. Inspection: and its diameter is -with the presence of considerably greater vaginal discharge; than normal. The Enlarged labia and hymen is clitoris, and permanently torn episiorraphy present. and heals with small, separate of tags of tissue. It takes the entire postpartal period for the vagina to involute until it
  • 29gradually returns toits approximateprepregnancy state.Source:Maternal and childhealth book 6thedition page 423:Adele Pillitteri