Peripheral Vascular

Inspecting the upper extremities, abdomen, and lower extremities no abnormalities

found. Palpation, pulse rate is 69bpm regular rhythm, thread equality and amplitude
is 1+. There are no thrills and temperature is 37C. Auscultation, arteries for bruits
none no problems on the lymph nodes or discoloration patient dont wear hose and
does not spend prolonged standing.

Musculoskeletal

Inspection: Posture is erect, head midline; body alignment is symmetrical spinal

curves in midline no spinal deformity.

Palpation: Muscle tone is normal, No involuntary movement, tenderness and atony.

No pain on Tinels test and Phalens Test.

Psychiatric

Family History, Emotional problems, changes in relationship. None. Mood swings (+)

1. Skin
Skin is intact with no lesions. Smooth and warm to touch. And dark brown in color.
Good skin rebound with no edema and no odor of perspiration. No pimples on face
and no swollen lymph nodes found
2. Hair
Hair is evenly distributed and no scalp dryness and scaling observed. Hair is short
thick in distribution. Tan and black in color. Uses shampoo and conditioner daily.
3. Nails
Color and shape of the nail is pink and no clubbing. It is clean and trimmed. Hard,
160 and firmly attached to nail bed. Good capillary refill and trims nails once a
week.
Head
Normocephalic and symmetrical. No nodule and masses observed.
Eyes
Symmetrical and aligned eyebrows and eyelids. No discharge and inflammation
noted. Sclera is white and clear. Cornea is smooth clear and opaque. No eye
infections and other abnormalities noted. The patient never had undergone any eye
surgery before and does not wear eyeglasses or contact lenses.

Ears
Ears are equally aligned in proportion to eyes. Auricles are smooth, light brown in
color and have no lesions. Pinna recoils after folded.
- Smooth and no drainage observed
- Can hear whispered voice loud and clear
- No ear infection or earache found
- Clear ears every other day.
Nose and sinuses
Nose in midline no deviation. Lining of the nose is smooth and deep pink. No flow in
the integrity as mucus freely through the nasal passage.
- Frontal and maxillary sinuses nontender. No other abnormality noted. The
patient does not use nasal spray or allergy sinus medication.
Mouth and Pharynx
Lips are pink and no inconsistency in integrity and free of lesions
- Gums and mouth are moist and pink.
- There are 30 teeth and no missing.
- Brush 3x a day and flosses once a day. White and clear.
- The patient does not use tobacco products.
Neck
Neck is light brown in color, symmetrical, no lumps and swelling noted.

- Trachea in midline and nontender

Breast and Axillae

Inspection: it is symmetrical, brown in color, no visible masses or lesions found.
Nipple and areola is circular in shape, symmetry and no discharges on nipple and
areola. No nodes palpated on axilla and clavicle.

Cardiovascular

There is no distention during inspection. Neck vessels rhythm is regular it is

symmetry and no thrills as palpated. Upon percussion and auscultation no
abnormalities found. No history of heart problems.

Respiratory

Inspection: Respiratory rate is 22 breaths/min, rhythm is normal and eupnea. Skin is

intact no accessory muscle use, no nasal flaring and barrel chest. Chest is smooth
as palpated and no abnormalities found. Resonance is heard as percuss. Upon
auscultation no abnormalities hears, breath sounds; vesicular is 1. No history of
breathing problems, history of allergies, current problems and patient is non-
smoker.

Gastrointestinal

Abdomen is rounded, smooth, and symmetric bilaterally. The condition of skin is

smooth, even with homogenous color, no lesions, and striae. Abdominal movement,
no pulsation and peristalsis. Bowel sounds is normal. No tenderness and dullness as
percussed indirectly. No bulges and good skin turgor. Non tender on deep palpation.
No abdominal pain is felt in testing for signs. Defecate every after meal.
Genitourinary

She refused to be assessed on the reproductive area and she has no complain of
pain upon micturation.

Nervous System

a) There is no problem mentioned in the impressions. Oriented to time and place.

Good in remote memory, Mathematical, General knowledge and vocabulary,
thought process and communication.

b) Test for Cranial Nerves:

CN I- Olfactory Nerve. No anosmia. Patient smelled and identified the substance CN

II- Optic Nerve. 20/20, good peripheral vision CN III,IV,VI,- Oculomotor. Trochlear,
Abducens Nerves is Good. CN V and CVII is normal. CN VII acoustic nerve. Can hear
and can balance herself. CN IX, X and CN XI is good. CN XII tongue position in
midline no atropy or fasciculation and tone.

c) Perform Sensory function Test - Intact

d) Test in light, pain, temperature, in various areas of the body is intact.

e) Deep sensations is performed well

f) Discriminatory sensations

Stereognosis and Graphestesia, Patient is able to identify familiar object.

g) Deep Tendon Reflex

Biceps and Triceps is 2+ Response: Flexion and extension at elbow is 2+

h) Superficial reflex all are positive

i) Check Glasgow Coma Scale (GSC) :

I. Motor Response is 6- Obeys commands fully.

II. Verbal Response is 5- Alert and Oriented.

III. Eye Opening is 4- Spontaneous eye opening

Score: GSC =15

Endocrine System

She doesnt have any history of endocrine disorder.

Hemapoeitic System
Upon inspection, there are no bruises or hematoma noted to her body and dont
have any history of bleeding disorder.

Lymphatic System

No swollen lymph nodes palpated.

Ensure proper healing of the perineum (tear or episio);

Patient will bathe the area twice a day in luke-warm water.

Ensure proper nutrition for the newborn;

Nurse will teach proper latch-on techniques.
Patient will demonstrate adequate breast-feeding/ bottle-feeding knowledge before being
released.
Education on a Safe Environment:

Continue good hygiene techniques

Get plenty of rest with good diet (sleep when baby is sleeping)

Management of Life-Threatening Conditions:

Women should be advised of the signs and symptoms of potentially life-threatening

conditions

When to contact their healthcare professional

Or call for emergency help if any signs and symptoms occur

Hygiene You may shower and wash your hair at any time.
Change your pads frequently and cleanse your self with warm water using your peri-bottle at
every change. Remember to wipe yourself from front to back. No douching or internal
tampons for 4-6 weeks or as indicated by your physician. Perineal stitches are absorbable
and do not need to be removed. If your stitches or hemorrhoids are sore and hurt, take a sitz
bath three times a day or discuss with your provider and use perineal wipes on your
 perineum or hemorrhoids. ConstipationAvoid constipation by eating a well-balanced diet
including fruits and vegetables and drink plenty of fluids. Stool softeners or mild laxatives
may be used. Family PlanningYour provider may advise that you not have sexual relations
for 4-6 weeks. Your period may return 6-8 weeks after delivery unless you are breastfeeding.
Some nursing mothers do not menstruate until weaning their baby from the breast; others
resume menstruation at various times while nursing. Pregnancy IS possible 4-6 weeks after
delivery before you get your period whether you are breastfeeding or not. Breast CareIf
breastfeeding, refer to breastfeeding handouts. If not breastfeeding, your breasts may still
become full and heavy. Wear a supportive bra. Do not handle your breasts or express milk. If
your breasts feel warm, apply ice packs under arms for 20 minutes to decrease discomfort.
Exercise/ RestTake frequent rest periods, especially when your baby is sleeping. Avoid lifting
anything heavier than the baby for 3-4 weeks. DO NOT start vigorous exercises until
approved by your provider. Perineal exercises can be started when you get home

X. Discharge Planning

Medications:

Continue taking the pre-natal vitamins given to you during your pregnancy.
They should be taken for 2-3 months after delivery and especially during the time
you breastfeed.

Ensure proper healing of the perineum (tear or episio);

Ensure proper nutrition for the newborn;
Nurse will teach proper latch-on techniques.
Patient will demonstrate adequate breast-feeding/ bottle-feeding
knowledge before being released.
Get plenty of rest with good diet

Hygiene: You may shower and wash your hair at any time.
Change your pads frequently and cleanse your self with warm water
using your peri-bottle at every change. Remember to wipe yourself
from front to back.
No douching or internal tampons for 4-6 weeks or as indicated by your
physician. Perineal stitches are absorbable and do not need to be
removed. If your stitches or hemorrhoids are sore and hurt, take a sitz
bath three times a day or discuss with your provider and use perineal
wipes on your perineum or hemorrhoids.
Constipation: Avoid constipation by eating a well-balanced diet
including fruits and vegetables and drink plenty of fluids. Stool
softeners or mild laxatives may be used.
 Family Planning: Your provider may advise that you not have sexual
relations for 4-6 weeks. Your period may return 6-8 weeks after
delivery unless you are breastfeeding.
Breast Care: If breastfeeding, refer to breastfeeding handouts. If not
breastfeeding, your breasts may still become full and heavy. Wear a
supportive bra. Do not handle your breasts or express milk. If your
breasts feel warm, apply ice packs under arms for 20 minutes to
decrease discomfort.
Exercise/ RestTake frequent rest periods, especially when your baby is
sleeping. Avoid lifting anything heavier than the baby for 3-4 weeks.
DO NOT start vigorous exercises until approved by your provider.
Perineal exercises can be started when you get home.