GENERAL ASSESSMENT

PHYSICAL ASSEMENT General physical assessment Pulse- - 79 beat /min24 Rr- 24 breath/min Temp-35.7 Head is round in shape. Hair is long, thick and coarse, straight and evenly distributed. Scalp is smooth and white in color Assessment of the eyes Her eyes are symmetrical, black in color, almond shape. Pupils constricts when diverted to light and dilates when she gazes afar, conjunctivas are pink. Eyelashes are equally distributed and skin around the eyes is intact. The eyes involuntarily blink Assessment of the ears Ears are clean, no ear wax was noted and approximately of the same size and shape. Patient can hear normally when spoken softly

Assessment of the head

Assessment of the nose

With

narrow

nose

bridge,

there

were

discharges noted upon inspection. No swelling of the mucous membrane and presence of nasal hairs were seen Assessment of the mouth She has a complete set of teeth with minimal

dental caries noted. Oral mucosa and gingival are pink in color, moist and there were no lesions nor inflammation noted. Tongue is pinkish and is free of swelling and lesions. Lips are symmetrical, appears pale without bits noted upon observation Assessment of the neck Neck has strength that allows movement back and forth, left and right. Patient is able to freely move her neck

Assessment of the lung and thoracic region

No reports of pain during the inhalation and exhalation. Absence of adventitious sounds upon auscultation. Respiratory rate 21 breathes per minute from the normal range of 16-20 breaths per minute

Assessment of the heart

Patient has an audible heart sound. PMI is heard between 4th - 5thintercostals space. Heart is pumping well with a pulse rate of 82 bpm from the normal rate of 60-100 beats per minute.

Assessment of the abdomen

Abdominal movement as with respiration, presence of peristalsis during auscultation. there is a presence of striae gravidarum.

Assessment of the upper extremities

Skin: White in color; Skin is smooth, moist and soft to touch Hands: Medium in size with approximately 5 fingernails in each side. Nails are short, small dusty particles are present Arms: Able to move through active ROM. Able to extend arms in front or push them out to the side

Assessment to the lower extremities

Size of the feet is undefined with lines on the sole. Ten fingers are present.Nailsarecleanandshort.

Assessment to Genitourinary

Without episiotomy, urinates 2-4 times a day and has not defecated yet since her deliver. absence of lesions and swelling Behavior Patient is silent but is conscious and coherent upon interaction. She sits and walks if she wants to. Motor Functioning -Able to move extremities through active ROM. Able to extend arms front and resist active as pushed down/up on his hands. Reflexes -reflexes were present such as the blinking reflex and deep tendon reflex. Sensory Functioning Patients sensory system is intact, she was able to distinguish touch, pain, hot and cold

Assessment of perineum Neurological Assessment