PHYSICAL

ASSESSMENT

February 11, 2016

Upon assessment, patient was on bed, awake, and afebrile with IVF D5LR for
keep vein open. The D5LR is useful for daily maintenance of body fluids and
nutrition, and for rehydration. She was cooperative and coherent throughout the
assessment. Her BP was 120/80,
Respiratory rate was 20, Pulse rate was 95 and temperature was 36.1; her vital signs
were all normal.

ASPECT NORMAL ACTUAL FINDINGS INTERPRETATION

FINDINGS AND
GENERAL ANALYSIS
APPEARANCE Proportionate with Patient's body Normal Findings
the body build, build, height, and
height and weight. weight is
Relaxed in an erect proportionate.
posture with The patient was
coordinated cooperative and
movement, clean has sense of
and neat, no body reality.
odor,
no breath odor, Height: 5'2
health in
PHYSICAL appearance,
DEVELOPMENT Appears to be Body is fully Normal Findings
stated at developed
chronological age
BEHAVIOR
Cooperative Cooperative Normal Findings
attitude and attitude, soft
behavior. spoken

MOOD
Plain or mild anxiety Plain Normal findings
DRESS
Dressed for Dressed in Normal Findings
occasion sleeping clothes,
a shirt and a
pajama

GAIT Erect posture, Not performed Not performed

coordinated, smooth
and steady gait

.
BODY BUILT Bilateral
developed
muscles.

LEVEL OF
CONSCIOUSNESS Alert and coherent. Alert and coherent. Normal Findings

PHYSICAL
ASSESSMENT I

BODY PART NORMAL ACTUAL FINDINGS INTERPRETATION

FINDINGS AND
ANALYSIS
Proportional to -The skull is round, Normal Findings
SKULL the size of the body proportional to the
round with size of the body,
prominences in with prominences
the frontal and in the frontal and
 occipital area area

-Symmetrical in all Symmetrical,
planes gently planes gently
curved curved
SCALP AND HAIR
-Clean, free from -Free from Normal Findings
masses, lumps, masses, lumps,
scars, nits, scars, nits and
dandruff, and lesions with
lesions presence of egg
lice
-Black evenly
distributed & -Hair is long,
covers the whole black, thick, and
scalp, thick/thin, evenly
shiny free from distributed
FACE
Symmetrical Symmetrical Normal Findings
facial facial
movements movements
EYES
Parallel and evenly Parallel, Normal Findings
placed, symmetrical, non
symmetrical, non- protruding, , both
protruding, with eyes are brown and
scant amount of clear
secretions, both
eyes are
EYEBROWS
Black, evenly Black, evenly Normal Findings
distributed, thick, distributed, thick,
can raise and lower can raise and lower
eyebrows eyebrows
symmetrically, symmetrically,
parallel to each parallel to each
other other
EYELASHES
Black evenly Black evenly Normal Findings
distributed and distributed and
pointing pointing
outward outward

EYELIDS
-Upper lids cover a -Upper lids cover a Normal Findings
small portion of the small portion of the
iris, cornea and the iris, cornea and the
sclera when the sclera when the
 are open. When the are open. When the
lids closed, the lids closed, the
lids meet lids meet
completely. completely.

Symmetrical color Symmetrical color
is the same is the same
at the surrounding at the surrounding
skin. skin.
LID MARGINS
Clear there is Clear there is Normal Findings
no scaling and no scaling and
secretions secretions

LOWER Salmon pink, Salmon pink, Normal Findings

PALPEBRAL shiny, moist and shiny, moist and
CONJUNCTIVA transparent transparent

White in color White sclera, clear Normal Findings

SCLERA and clear

IRIS Proportional to Proportional to Normal Findings

the size of the the size of the
eye, round, eye, round,
black/brown and black/brown and
symmetrical symmetrical
PUPILS
From pinpoint to From pinpoint to Normal Findings
almost the size of almost the size of
the iris, round, the iris, round and
symmetrical, symmetrical, pupils
constrict with equally round, react
increasing light to light and
accommodation accommodatio
n
EYE MOVEMENT
Able to move in all -Able to move in Normal Findings
directions and full all directions and
of motion full of motion
 20 distance can Can read Normal Findings
VISUAL ACUITY the eye sees and newsprint no
20 distance the difficulty in
eye can read reading
FIELD OF VISION
Able to see Patient was able Normal Findings
60degrees to move eyes in
superiorly, full range of
90degrees, motion.
temporally,
and
NOSE 70degrees inferiorly
Midline, patent Midline, patent Normal Findings
and symmetrical and symmetrical

INTERNAL NARES
Clean, pinkish, Clean, pinkish, Normal Findings
with few cilia with few cilia

NASAL SEPTUM
Straight Straight Normal Findings

LIPS
-In white skin: Pink Dry, symmetrical lips Interpretation:
In dark skin: May The client has dry
have bluish blue or lips.
freckle like
pigmentation Analysis:

-Moist, smooth with

no lesions

GUMS
-Pinkish, smooth, -Pinkish, smooth, Normal Findings
moist, no swelling moist, no swelling
and no retraction and no retraction

TEETH
-Well aligned, free -29 misaligned Interpretation:
from dental caries teeth, upper teeth
and no halitosis with The patient has
dental caries, 4 misaligned teeth,
missing teeth, extra dental caries and
tooth eruption on extra tooth eruption
upper left portion of
 gums.

Analysis:

Gingival tissue
tends to
hypertrophy during
pregnancy.Tooth
decay occurs from
the action of
bacteria on sugar.
This action lowers
the pH of the
mouth, creating an
acid medium that
leads to etching or
destruction of the
enamel of teeth.

(Promoting Fetal
TONGUE
-Pinkish, moist -Pinkish, moist Normal Findings
and freely and freely
movable movable

FRENULUM -Midline, straight -Midline, straight Normal Findings

CHEEKS
(BUCCA -Pinkish, moist, -Pinkish, moist, Normal Findings
L and smooth and smooth
MUCOS
A)
PALATE
-Pinkish, moist -Pinkish, moist Normal Findings
SOFT and smooth and smooth

PALATE -Slightly pinkish -Slightly pinkish

HARD
UVULA
-At the center, -At the center, Normal Findings
symmetrical, and symmetrical, and
freely movable freely movable

TONSILS
 -Pinkish, non- -Pinkish, no Normal Findings
inflamed, no exudates
exudates

VOICE
No hoarseness No hoarseness Normal Findings
and well- and well-
modulated modulated

NECK
-Proportional to the -Proportional to the Normal Findings
size of the body size of the body
and head, and head,
symmetrical and symmetrical and
straight. straight.

-No palpable -No palpable

masses or area of masses or area of
tenderness. tenderness.
-Freely movable -Freely movable
RANGE OF Freely movable Freely movable Normal Findings
MOTION without difficulty without difficulty

-Symmetrical and -Symmetrical and Normal Findings

able to resist able to resist
MUSCULAR applied force (both applied force (both
STRENGTH muscles) muscles)

-Symmetrical -Symmetrical
in structure of in structure of

PHYSICAL
ASSESSMENT II

BODY PART NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

AND
ANALYSIS
 Inspection: Inspection: Normal Findings
THORAX AND
LUNGS -The chest contour -The chest contour
is symmetrical and is symmetrical. The
the chest is as wide spine is straight. .
as deep (antero- There is no bulging
posterior diameter or retraction of the
in a 1:2 ratio). The ICS during
spine is straight. breathing. The
Posteriorly, the ribs chest wall moves
tend to slope across symmetrical during
and down. The ribs respiration.
are prominent in a
thin person. There is
no bulging or
retraction of the ICS
during
breathing. The chest
wall moves
symmetrical during
respiration.

Palpation: Normal Findings

Palpation:
-No lumps, masses
-No lumps, masses and or areas of
and or areas of tenderness was
tenderness. Sides palpated. Sides of
of the thorax the thorax expand
expand symmetrically. The
symmetrically. The thumb separates
thumb separates approximately 4
approximately 3-5 cm during
cm during excursion Normal Findings
excursion.
Percussion:
-Location
Percussion: Percussion Note
-Location Left and Right
Percussion Note Left Supraclavicular
and Right both flat
Supraclavicular
both flat 1st ICS both
resonant
1st ICS both 2nd ICS dull,
resonant resonant
2nd ICS dull, 3rd ICS dull,
resonant resonant
 Relatively equal -The client has
with slight darkened areola,
variation, round has striae with
and pendulous, pregnancy
Breast non tender, no
masses or Analysis:
nodules
The client has
darkened areola,
has striae with
pregnancy

Interpretation:

Subtle changes
in the breast may
be one of the first
physiologic
changes of
pregnancy a
women notices. As
the pregnancy
progresses, the
areola of the nipple
darkens and its
diameter increases
from about 3.5 cm
to 5 or 7.5 cm.
HEART
-Aortic valve -Aortic valve Normal Findings
no pulsations no pulsations

-Pulmonic area -Pulmonic area

no pulsations no pulsations

-Tricuspid area -Tricuspid area

pulsations are pulsations are
visible and visible and
palpable palpable

-Apical area -Apical area

abdominal aortic abdominal aortic
pulsations visible pulsations visible
and palpable. and palpable.
 loudest at apical loudest at apical
area. area.
ABDOMEN
Inspection: Inspection: Analysis:

-Skin is -The client has The client has

unblemished, no striae gravidarum- striae gravidarum-
scars, color is pink or reddish pink or reddish
uniform, streaks appearing streaks appearing
symmetrical on the sides of the on the sides of the
movements caused abdominal wall abdominal wall
by respiration, and visible linea and visible linea
umbilicus is flat or nigra nigra
concave, positioned
midway between Interpretation:
the Xyphoid
process and the As the uterus
symphysis pubis, increases in size,
color is the same as the abdominal wall
the surrounding Auscultation: must stretch to
skin. accommodate it.
5 bowel sounds The stretching can
-Auscultation: cause rupture of
the atrophy of
There are clicks small segments of
and gurgles, the the connective
frequency of 5-34 Percussion: layers of
per min. the skin. During the
- Mostly tympanic weeks after birth,
Percussion: all over the striae gravidarum
abdomen. lighten to a silvery-
-Tympanic white color,
predominates and, although
because permanent,
of the presence of they become
air in barely
the stomach and noticeable.
intestines.
Percussion is dull Palpation: Extra
at the livers lower pigmentation
border. No tenderness, generally appears
no lumps and on the abdominal
Palpation: masses felt or wall. A
seen. narrow, brown line
-Soft abdomen, may form, running
no tenderness, no from the umbilicus
muscle guarding, to the symphysis
no lumps or pubis and
 Physiologic
Changes of
Pregnancy, pgs
233-
234 by Adele
Pillitteri)

PHYSICAL
ASSESSMENT III

BODY PART NORMAL ACTUAL FINDINGS INTERPRETATION

FINDINGS AND
ANALYSIS
UPPER -Skin color varies, -Symmetrical, fair Normal Findings
EXTREMITIES symmetrical, fine skin tone, fine hair
ARM hair evenly evenly distributed,
distributed,
presence/absence
of visible veins.
DORSAL -Soft and elastic -Soft and elastic Normal Findings
SURFACES

NAILS -Nails are Nails are Normal Findings

transparent, transparent, -
smooth, and smooth, and
convex with pink nail convex with pink nail
beds and beds and
white white
translucent translucent
tips. tips.

-As pressure is
applied to the nail As pressure is
bed appear white. applied to the nail
Capillary refill less bed appear white.
than two seconds. Capillary refill is
immediate.

Range of Motion- -The client Normal Findings

SHOULDERS Performs with performed the
relative ease procedure with
relative ease
ARMS Range of Motion- -Performs with Normal Findings
Performs with relative ease
relative ease

ELBOWS Range of Motion- -Performs with Normal Findings

Performs with relative ease
relative ease

-Uniform skin -The client has Analysis:

LOWER color with light striae and
slightly darker varicose veins The client has
EXTREMITIES exposure area. from previous light striae and
pregnancies. varicose veins
LEGS - No jaundice, from previous
cyanosis, pallor or pregnancies.
erythema
Interpretation:
-No presence of
edema Smooth, Varicosities, or the
firm and non development of
tender tortuous leg veins,
are common in
pregnancy
because the
weight of the
distended uterus
puts pressure on
the veins returning
blood from the
lower extremities.

(Promoting Fetal
TOES -Five toes on each -Five toes on each
foot foot
-Sole and dorsal -Sole and dorsal
surface surface
is smooth: with is rough: with pink
pink nail beds nail beds and
 ANATOMY AND PHYSIOLOGY

The female reproductive system consists of external and internal pelvic structures.
Other anatomic structures that affect the female reproductive system include the
hypothalamus and pituitary gland of the endocrine system.

Internal Organs:

A) Uterus

The uterus is a hollow organ about the size and shape of a pear. It serves two
important functions: it is the organ of menstruation and during pregnancy it
receives the fertilized ovum, retains and nourishes it until it expels the fetus
during labor.

Divisions of the uterus. The uterus consists of the body or corpus, fundus, cervix,
and the isthmus. The major portion of the uterus is called the body or corpus.
The fundus is the superior, rounded region above the entrance of the fallopian
tubes. The cervix
is the narrow, inferior outlet that protrudes into the vagina. The isthmus is
the slightly constricted portion that joins the corpus to the cervix.
B) Vagina

The vagina is the thin in walled muscular tube about 6 inches long leading from
the uterus to the external genitalia. It is located between the bladder and the
rectum.

The vagina provides the passageway for childbirth and menstrual flow; it
receives the penis and semen during sexual intercourse.

C.) Fallopian Tubes (Two)

The fallopian tubes transport ovum from the ovaries to the uterus. There
is no contact of fallopian tubes with the ovaries.

The most desirable place for fertilization is the fallopian tube.

D.) Ovaries

The ovaries are for oogenesis-the production of eggs (female sex cells)
and for hormone production (estrogen and progesterone).

As the developing egg begins to ripen or mature, follicle enlarges and develops
a fluid filled central region. When the egg is matured, it is called a graafian
follicle, and is ready to be ejected from the ovary.

Process of egg productionoogenesis

The total supply of eggs that a female can release has been determined by the
time
she is born. The eggs are referred to as oogonia in the developing fetus

At puberty, the anterior pituitary gland secretes follicle-stimulating hormone

(FSH), which stimulates a small number of primary follicles to mature each
month.
 Follicle development to this stage takes about 14 days. Ovulation (ejection of
the
mature egg from the ovary) occurs at this 14-day point in response to the
luteinizing hormone (LH), which is released by the anterior pituitary gland.

The luteinizing hormone also causes the ruptured follicle to change into a
granular structure called corpus luteum, which secretes estrogen and
progesterone.

Process of hormone production by the ovaries

Estrogen is produced by the follicle cells, which are responsible
secondary sex characteristics and for the maintenance of these traits

hese secondary sex characteristics include the enlargement of fallopian tubes,

uterus, vagina, and external genitals; breast development; increased deposits of
fat in hips and breasts; widening of the pelvis; and onset of menses or menstrual
cycle.

Progesterone is produced by the corpus luteum in presence of in the blood. It

works with estrogen to produce a normal menstrual cycle. Progesterone is
important during pregnancy and in preparing the breasts for milk production.

External Female Organs

A)Mons Pubis

This is the fatty rounded area overlying the symphysis pubis and covered with
thick coarse hair.
B) Labia Majora

The labia majora run posteriorly from the mons pubis. They are the 2 elongated
hair covered skin folds. They enclose and protect other external reproductive
organs.

C)Labia Minora

The labia minora are 2 smaller folds enclosed by the labia majora. They
protect the opening of the vagina and urethra.

D)Vestibule

The vestibule consists of the clitoris, urethral meatus, and the vaginal
introitus.

The clitoris is a short erectile organ at the top of the vaginal vestibule
whose function is sexual excitation.

The urethral meatus is the mouth or opening of the urethra. The urethra is a
small tubular structure that drains urine from the bladder.

The vaginal introitus is the vaginal entrance.

E)Perineum

This is the skin covered muscular area between the vaginal opening
(introitus) and the anus. It aids in constricting the urinary, vaginal, and anal
opening. It also helps support the pelvic contents.

F) Bartholins Glands (Vulvovaginal or Vestibular Glands)

The Bartholins glands lie on either side of the vaginal opening. They produce
a
mucoid substance, which provides lubrication for intercourse.

BLOOD SUPPLY

The increased demands of pregnancy necessitate a rich supply of blood to the

uterus.
New, larger blood vessels develop to accommodate the need of the growing
uterus. The venous circulation is accomplished via the internal iliac and
common iliac vein.
The Menstrual Cycle
Menstruation is the periodic discharge of blood, mucus, and epithelial cells
from the uterus. It usually occurs at monthly intervals throughout the
reproductive period, except during pregnancy and lactation, when it is usually
suppressed.

The menstrual cycle is controlled by the cyclic activity of follicle stimulating

hormone (FSH) and LH from the anterior pituitary and progesterone and
estrogen from the ovaries. In other words, FSH acts upon the ovary to
stimulate the maturation of a follicle, and during this development, the follicular
cells secrete increasing amounts of estrogen

Ovulation
Ovulation is the release of an egg cell from a mature ovarian follicle.
Ovulation is stimulated by hormones from the anterior pituitary gland.

After it is expelled from the ovary, the egg cell and one or two layers of
follicular cells surrounding it are usually propelled to the opening of a
nearby uterine tube.

If the cell is not fertilized by union of a sperm cell within a relatively short time,
it will degenerate.

Menopause

Menopause is the cessation of menstruation. This usually occurs in women

between the ages of 45 and 50.

Menopause generally means cessation of regular menstruation. Ovulation

may occur sporadically or may cease abruptly.