The physical assessment of the patient found mostly normal findings with a few notable exceptions. The patient's skin showed increased melanin production resulting in darker pigmentation on her neck. Her nails were softened and thinned as is normal during pregnancy. No other significant abnormalities were found.

1. 16
IV. PHYSICAL ASSESSMENT
Area to be assessed Normal findings Actual findings Analysis
1. General
Appearance
Mood and affect Appropriate to She’s cooperative She’s slightly
situation/ cooperation upon the assessment recovered
Signs and distress No distress noted Slightly distress Due to after pain’s
of pregnancy
Posture Relaxed erect posture The patient is relaxed NORMAL
Body movement Coordinated Able to do NORMAL
movement coordinated
movements
Hygiene 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 beliefs
Type of clothing Clean and The client has clean Able to practice
presentable clothing and presentable good clotting
clothing
2. Measurements
Height 5’4’’
Weight 54 kg
BMI 18.5-24.9 21.09 NORMAL
3. Vital signs
Temperature 36.5⁰C-37.5⁰C 36.9⁰C NORMAL
Pulse rate 60-100 bpm 75 bpm NORMAL
Respiratory rate 12-20 cpm 20 cpm NORMAL
Blood 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

2. 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 625
Eyebrows Inspection:
-hair evenly -the hair evenly NORMAL
distributed; skin distributed and skin
intact is intact
-eyebrows -symmetrically
symmetrically aligned and equally
aligned; equal move
movement
Eyelashes Inspection:
-Hair is evenly -hair is evenly NORMAL
distributed; distributed and curled
-slightly curled slightly outward
outward
Eyelids Inspection:

3. 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 ptosis
Conjunctiva(bulbar) Inspection:
-transparent; -transparent, NORMAL
capillaries sometimes capillaries sometimes
evident; sclera evident
appears white -sclera is white
Palpebral 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

4. 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

5. 20
glands gland
-dry cerumen -dry cerumen
-pearly gray color, -pearly gray and semi
semi transparent transparent
-no skin lesions -no skin lesions
Hearing 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 edema
Buccal 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

6. 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 611
Tongue/ 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

7. 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
Thorax
Posterior 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

8. 23
-resonate, except
over scapula -resonate, except
-lower point of over scapula
resonance is at the -lower point of
diaphragm resonance is at the
-diaphragmatic diaphragm
excursion, excursion -1.5 inches
is 3-5 cm (1 ½ to 2
in) bilaterally
-diaphragm is usually
slightly higher on the -diaphragm is usually NORMAL
right side slightly higher on the
Auscultation: right side As the pregnancy
-vesicular and progresses,
bronchovesicular -vesicular and progesterone
breath 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

9. 24
Anterior 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 periphery
Vascular 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 sternum
Carotid arteries Palpation:
-symmetric pulse -symmetric pulse NORMAL

10. 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 supine
Head
Skull 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 masses
Scalp 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 tenderness
Hair 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

11. 26
Face 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 brown
Breast 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 626
Areola 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

12. 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 611
Sub 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
tension
Musculoskeletal system

13. 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
nodules
Upper 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

14. 29
gradually returns to
its approximate
prepregnancy state.
Source:
Maternal and child
health book 6th
edition page 423:
Adele Pillitteri