Delivery Room: Assessment

I. Profile:

Name: Patient D
Sex Female
Age: 22 y/o
OB Score: G2P1
Occupation: Housewife
Nationality: Filipino
Date and Time of Admission: November 8 2019, 10:00AM
LMP: February 14, 2019
AOG: 32 weeks

II. Physical Assessment:

Date Assessed: November 8, 2019

General Survey: 22 year-old client was received alert, oriented, cooperative, who appears to be
experiencing labor

Vital Signs:
 TECHNIQUE ACTUAL
PART NORMAL FINDINGS INTERPRETATION
USED FINDINGS
INTEGUMENT
Skin generally uniform except in areas
Skin is generally
Skin exposed to sun; varies from light to
uniform in color
dark brown

No edema

Uniform skin temperature; within

Palpation
normal range

Evenly
Evenly distributed hair; thick hair; distributed hair;
Hair Inspection Normal
silky resilient thick hair; silky
resilient
No infection or
Inspection No infection or infestation Normal
infestation

Nails Inspection Convex curvature; Pink in color

HEAD
Skull Inspection Normocephalic Normocephalic Normal

Symmetrical
Face Inspection Symmetrical facial features Normal
facial features

Eyes
Inspection Eyebrows are evenly distributed
(External)
Eyelashes are
Inspection Eyelashes are equally distributed equally
distributed
Eyelids skin
Inspection Eyelids skin intact, no discharge intact, no
discharge
Eyelids close
Inspection Eyelids close symmetrically
symmetrically
Inspection No edema No edema
Eyes
Inspection White sclera White sclera
(Internal)
Palpebral
Palpebral conjunctiva; shiny, smooth, conjunctiva;
and pink or red shiny, smooth,
and pink or red
 Pupils black in
Pupils black in color
color
Both eyes
coordinated
Both eyes coordinated move move
in unison with parallel alignment in unison with
parallel
alignment

Ears Inspection Color same as facial skin

Symmetric and
straight;
Symmetric and straight;
Nose Inspection No discharge or
No discharge or flaring; Uniform color
flaring; Uniform
color

Inspection Outer lips pink in color, soft, moist

Mouth
smooth texture
Inspection Symmetrical contour

Inspection
Inner lips and buccal mucosa appears
uniform pink color, moist smooth,
glistening and elastic

Inspection
Tongue central position, pink color,
smooth, lateral margins; no lesions,
move freely

NECK
Inspection Neck muscles
Neck Neck muscles equal in size
equal in size
Inspection Trachea in center
Trachea Trachea in center of the neck
of the neck
Thyroid Inspection Thyroid glands
Thyroid glands not visible
Gland not visible

THORAX AND LUNGS

Full and
Thorax
Inspection Full and symmetric chest expansion symmetric chest
and Lungs
expansion
 CARDIOVASCULAR AND PERIPHERAL VASCULAR SYSTEM

Carotid
Palpation Symmetric and full pulsations
arteries
Capillary
Refill Test
on Immediate return of color (About 5
Inspection
Fingernail seconds)
and
Toenail

BREASTS
Rounded shape; slightly unequal in
Breast Inspection
size; generally symmetric
Skin uniform in color (similar to skin
of
abdomen if not tanned)
Skin smooth and intact
Presence of striae
Round or oval and bilaterally the
same;
Areola Inspection
Color varies from light pink to dark
brown
Nipples Inspection Round, everted, and equal in size

ABDOMEN
Skin is lighter in
color compared
Skin is uniform in to the rest of the
Inspection
color, unblemished body, linea
nigra is visible
upon inspection
Symmetrical
contour
Symmetrical
Inspection but changes
contour
upon
movement
Musculos
keletal
System
 Muscles equal in
both sides of the
body; no
Muscles equal in
pulsations or
both sides of the
tremors; firm;
body; no pulsations or tremors; firm;
smooth and
smooth and coordinated. Equal in
coordinated.
strength.
Appear generally
weak upon
inspection

FEMALE GENITALS

Uterus