D.

Past History

1. Previous deliveries

The client delivered her first child via a normal spontaneous delivery. There is no
complication during the delivery. The OB score is G2P1. She delivered

2. Allergies(food, environment, drugs, etc)

The client does not have any allergies with the environment, drugs and foods
according to her.

3. Past illness

The client had a chicken pox when she was a child, but she was never exposed
in any serious diseases like STD and herpes. She didn’t have any injuries but she was
hospitalized in 2006 due to hyperthyroidism and was treated with radio active iodine.

4. Medication

The client is taking ferrous sulfate and amino acid. She takes it once a day
before going to bed. It is prescribe by her obstetrician.

CHAPTER TWO-REVIEW OF SYSTEM

A. Physical assessment

General appearance

The client has a medium frame, smooth rhythmic gait. Well groomed and has no
body odor. She is 165 lbs. and 5’2” in height. Her temperature is 36.5 c, blood pressure
is 120/80 mmHg, respiratory rate is 27 breaths per minute, cardiac rate is 83 beats per
minute, pulse rate is 89 beats per minute and her fundic height is 26.5 cm

Skin

The client’s skin is of normal racial tone. There is an edema +1. Skin is dry and
smooth. The skin turgor is elastic and mobile. The body hair is evenly distributed.

Hair

The client’s hair are evenly distributed she doesn’t have any tenderness,
depression, nodules and infestation. The hair is fine and shiny.

Nail

The client’s nail plate shape is convex 160°, the nail is smooth and the nail bed is
pink. The capillary refill is within 3 seconds and there are no presences of beau’s line.

Head and Face

The client’s skull is proportionate to the body size;there were no tenderness in

the scalp. Her hair is evenly distributed and the strands are thick and shiny. Her head is
 round and symmetrical the consistency is hard. She can control her head and the shape
of her face is round and symmetrical and the consistency is soft.

Eyes

The condition of her eyes is straight normal; the eye brows are evenly distributed.
Eyelids have effectively closure. The blink response is bilateral, eye balls are
symmetrical, bulbar conjunctiva is clear, the palpebral conjunctiva is pink and the sclera
is white. Pupils are equal in size. Pupils are equally round and reactive to light and
accommodation. She can execute the occular movements. She can recognize objects
within 12-14 inches away. The lacrimal apparatus are moist.

Ear

The color of the ears is of normal racial tone and it is symmetrical. The pinnas
are elastic and recoil when folded. It doesn’t have any masses and tenderness. The
external canal has some cerumen. The color of the cerumen is brown.

Nose

Nose is of normal racial tone her septum is in the midline, mucosa is pink.
Nostrils are both patent. Nasal flaring is absent. She doesn’t have any tenderness in her
sinuses.

Mouth
The lips is symmetrical and pink, the consistency is smooth, buccal mucosa is
pink, the gum is pink, the tongue is in the midline, the color is pink and it is smooth. The
tongue movements are smooth the color of the hard and soft palate is pink. And it is
intact. The oropharynx is color pink as well as the tonsils. All the teeth are complete.
She doesn’t have any tooth decay.
Throat

Uvula is in the midline, mucosa is pink, tonsils are not inflamed and the gag
reflex is present.

Neck

Neck muscles are equal in size she can resist force when ask to resist. Muscle
strength is 5/5. The trachea is in the midline.

Breast

The client’s breasts are symmetrical, the shape is round and the contour is
round. Areolas are pink and round, nipples are symmetrical and everted. There are no
presence of masses and cyst. And she doesn’t have any tenderness.

Chest and Lungs

The color of the chest is of normal racial tone, the shape is AP to lateral ratio 1:2.
There are absent of intercoastal retraction, costal angle is 45 ° chest wall are
symmetrical, and the chest expansion is symmetrical. Rib slope is less than 90.
Respiratory rhythm is regular. The respiratory depth is shallow. Respiratory pattern is
normal. When palpated she doesn’t felt any tenderness. The vocal fremitus is equal,
tactile fremitus is symmetrical. The lung expansion is normal. When percussed the
sound is resonance. When auscultated the breath sounds is brondial.

Abdomen

The skin is of normal racial tone, the contour is round, and peristalsis is non-
visible. Color of the stool is brown, the consistency is solid and the characteristic is
formed. The bowel sounds are normoactive. There is presence of linea nigra and striae
gravidarum.
Genital

According to the client, her pubic hair is evenly distributed, the clitoris is in the
midline and the urethral orifice is in the middle and there is presence of Leukorrhea. The
discharges don’t have any foul odor. According to the client her vagina is color violet.

Upper extremities
The client can resist force when asked to resist. Muscle strength is 5/5. The
peripheral pulses are equal. Lympnodes are not palpable. There is an edema +1 on her
index finger
Lower extremities

The client can resist force when asked to resist. Muscle strength is 5/5. She has
a varicosveins her left foot. She doesn’t have any deformity. The peripheral pulses are
equal. Lympnodes are non-palpable