Assessment of Systems

(Postpartum)

Initials of Client: M.M. Age: 23

Body Part Examined Assessments Actual Findings

Head  Inspect hair for distribution, thickness,  The client’s hair is clean, has a good hair
excessive dryness or oiliness and distribution and thickness, no excessive dryness
cleanliness or oiliness.
 Palpate hair for firmness and strength  The client’s hair is firm upon palpation.
Face  Inspect for edema on the face (puffy  Edema is not present upon inspection on the
eyelids, prominent fold of tissue client.
inferior to the lower eyelid)

Eyes  Inspect the color and texture of the  The inner conjunctiva appears lightly shaded.
inner conjunctiva.

Neck  Inspect for thyroid hypertrophy.  Thyroid hypertrophy is not present upon
inspection.
Breast  Inspect the breast for size and  The breast size has increase and feels soft upon
consistency. palpation.
 No lesions  Lesions are not observed.
 Inspect the nipples for cracks, fissure  Cracks, fissures and presence of caked milk is
or presence of caked milk not present upon inspection.
 Palpate for warmness and tenderness.  The breast is warm and minimal tenderness is
noted upon palpation.
 Palpate for nodules.  Palpable nodules are not present.
Uterus  Inspect abdomen for contour,  No distention and minimal appearance of striae
distention and appearance of striae or was observed.
diastasis.
 Palpate fundus and assess consistency  Palpation of the fundus is firm, not tender and
and location. at midline.
Lymph Nodes  Lymph nodes should not be palpable.  The client’s lymph node is not palpable.
Lungs  Assess respiratory rate and rhythms.  The client’s respiratory rate is 18 cycles per
minute.
 Assess the vital capacity.  The vital capacity of the lungs is not reduced.
 Assess the client’s diaphragmatic  The diaphragmatic excursion is lessened.
excursion.
Back  Inspect spine for any abnormal curve  The client’s spine is accentuated and has no
that would suggest scoliosis. abnormal curve upon inspection.
Extremities and  Inspect for palmar erythema and  Palmar erythema is not present upon
Skin itching. inspection.
 Assess the lower extremities for  Minimal varicosities are present and no edema.
varicosities and presence of edema.
 Assess the nails for capillary refill.  The client’s capillary refill is less than 1 second.
 Assess the gait.  The client has a waddling gait.