PERSON ASSESSMENT

PHYCHOSOCIAL
Assessment 1st Assessment 2nd Assessment Interpretation

(October 8, 2021) (October 9, 2021)

Significant Others: The father is seen supporting The father is the one who That means the father have care in the
and responsible for escorting the guarded and stayed with the health of mother.
Husband mother during admitting her to patient.
hospital.
Structure of Family Nuclear Nuclear Group of people who are united by ties
of partnership and parenthood and
consisting of a pair of adults and their
socially recognized children.
Coping Mechanism The father is assisting and The father is assisting and The father is very responsible
talking to the patient talking to the patient
Religion Roman Catholic When it comes to religion the mother
beliefs and practices of the Roman
Catholic.
Primary Language Ilocano, English, Tagalog The mother can understand Ilocano,
Tagalog, and English language.
Primary Source of Health Care Hospital Hospital Due to financial stability, she was
admitted to a private room.
Financial Resources Her salary and from her partner They both pay for their expenses.
Occupation Teacher Job that involves a contractual
commitment, that you go to every day,
and perform according to your
administrator's requirements.
Education College graduate – Bachelor of The mother has obtained a bachelor's
Secondary Education major in degree.

General Appearance  The client is
appropriately dressed for
her age and weather.
 The client appears to be
in her stated age.
The client shows a slightly
bended posture, was not able to
maintain eye contact and was
restless.
Affect  The client shows
frowning facial
expression in relation to
emotions.
The client is in pain because she
was not able to talk as she
whimpers
Speech Patient is not able to speak at all
as she experiences pain
Non- Verbal behavior frowning and does facial
grimaces
Memory
Immediate Memory
English
 The client is
appropriately dressed for
her age and weather.
 The client appears to be
in her stated age.
The client shows postpartum
posture, able to maintain eye
contact and shows appropriate
facial expression.
 The client shows
appropriate facial
expressions in relation to
emotions.
The client is happy because she
talked in a nice way and feels
comfortable to us.
The client is well oriented
Understandable, moderate pace,
Thought Association
Patient smiles and nods during
the interview
Intact
•Immediate memory is good
because she can follow our
instructions to repeat the
In the 1st assessment the mother is
unable to relax in a normal state because
she is experiencing pain.
In the 2nd assessment the mother is in
the normal state with mild pain.
In the 1st assessment the mother is
unable to relax in a normal state because
she is experiencing pain.
In the 2nd assessment the mother is in
the normal state with minimal pain.
In the 1st assessment the mother can’t
speak normally due to pain that she is
experiencing
In the 2nd assessment Can speak
normally with a normal voice tone
In the 1st assessment the mother was
seen to have hard time due to her facial
expression
In the 2nd assessment the mother was
seen to be okay.
She is well-conscious
The mother was able to comply to
immediately and consciously processed.
 numbers “3,5,7,9”

Patient: “3,5,7,9”
Relevance and Association Logical sequence make sense, The patient is talking with sense means
Thoughts Exhibits has sense of reality she is thinking normally
Recent memory •Recent memory is good The mother was able to remember.
because she can recall the time
of admission

Patient: “Kahapon lang po mga

10 ng umaga”
Remote Memory •Remote memory is good The mother was able to recall or
because 0she can recall the year remember even it is long-term memory
of her marriage.

Elimination

Assessment 1st Assessment 2nd Assessment Interpretation

(October 8, 2021) (October 9, 2021)

Stool Did not yet discharge feces 2nd Assessment

from the body. Because of the presence of RELAXIN
which relaxes the ligaments in the pelvis
and softens and widens the cervix.
Urination The client previously urinated 2nd Assessment
about 100mL, yellow pale light It's also normal to urinate more
in color frequently
st
Abdomen It is firm, and the fundus Still Firm, and the fundus is 1 Assessment
 underneath the sternum
Prominent striae gravidarum
and Linea nigra
Toileting Ability
Lochia
ENVIRONMENT
Assessment 1st Assessment
approximately 1 fingerbreadth
underneath umbilicus
Prominent striae gravidarum
and Linea nigra
Since the patient can’t move in
her own, she needs support of
others to move slowly.
Frequency: 3 pads per day
Type: Rubra
Color: Red
Odor: None present
Clot size: Small
2nd Assessment
part drops into the pelvis as fetal
presenting
linear tears in dermal collagen and
commonly noted
2nd Assessment
Since the client is only 1 day to her
postpartum it is still palpable, and it is
precisely 1 fingerbreadth below the
umbilicus
stretch marks usually become
considerably less noticeable about six to
12 months after childbirth.
2nd Assessment
Because your womb (uterus) is
contracting and going back to its normal
size. These pains usually last for 2 or 3
days after a straightforward vaginal
delivery.
nd
2 Assessment
Lochia rubra occurs on days two to five
[post-birth] and is when the bleeding is at
its heaviest. Your blood will be red and
very heavy. It's also normal to see clots
during this stage.
Interpretation
 (October 8, 2021) (October 9, 2021)
Allergies/ Reaction
Medication The patient is not allergic on The patient is not allergic on
medications medications
Food The patient is not allergic on The patient is not allergic on
foods foods
Environment The patient is not allergic on The patient is not allergic on
environment environment
Eyes/ Vision PERRLA Pupils, Equal
, Round, Reactive (to), Light,
Accommodation.
Hearing/ Hearing Aid The client stated that she
doesn’t not use hearing aid
because her hearings are
normal
Have a normal voice and
The mother shows no allergic reactions
on medications.
The mother doesn’t have allergies
when it comes to foods
The mother stay in hospital shows no
allergies.
nd
2 Assessment
Equal: pupils are equal in shape and
size.
Round: pupils are round
Reactive to light and
accommodation: pupils get smaller in
bright or direct light, as well as when a
person focuses on something very close
to their eyes.
The appearance and function of pupils
of the patient is good and normal
2nd Assessment
The hearing ability of the patient and
response are indicated normal
 audible

Able to comply in counting

6,7,8.9
Skin As we pinch the clients  Patient’s skin turgor goes 1st assessment
skin turgor goes back back immediately to its
immediately to its original state after The patient is not dehydrated.
original state after pinching
pinching and there is no
occurrence of skin  (Presence of episiotomy) 2nd Assessment
lesion
An episiotomy is a cut The patient is not dehydrated.
(incision) through the area
between your vaginal It is normal to feel pain or soreness for
opening and your anus. 2-3 weeks after giving birth,
This area is called the particularly when walking or sitting.
perineum. This procedure
is done to make your
vaginal opening larger for
childbirth.

Mucous Membrane  The septum is in the 2nd Assessment

middle and the turbinate’s
project into the nasal
passages. There is The in general the assessment of
sufficient room for the mucous membrane of the patient is
nasal passages. normal

 The mucous membrane is

red and compact over the
turbinate’s.
Temperature In right axillary 37.5°C In right axillary 37°C It is normal
 REST AND ACTIVITY
Assessment 1st Assessment 2nd Assessment Interpretation

(October 8, 2021) (October 9, 2021)

Current Activity Level Patient can be able to do limited 2nd Assessment

activities. Since the patient is still experiencing
fatigue and pain her activities are set to
limit and need the support of her husband
in executing it.

ADLs (the client is able to): 2nd Assessment

It can be seen that the patient
Groom can comb herself
Feed Herself Patient was able to feed herself
without the assistance of the
others.
Move Patient needs support or Patient needs support or
assistance in walking. assistance in walking.
It seems the patient can some of her
groom independently.
2nd Assessment
The mother can be seen that she can eat
by herself.
st
1 Assessment
Since she is experiencing mild pain in
lower abdomen, she will be needing a
support or assistance.

2nd Assessment
Since she is experiencing mild pain in
lower abdomen, she will be needing a
support or assistance
Communicate The patient is at state of 1st Assessment
The patient is at state of normality and can now talk Since the patient is experiencing pain,
 impatience at hear face and naturally and in proper words
cannot be able to talk
naturally and have slight
improper words pronunciation
Sleep With an episodic sleep of
pattern patient slept for less
than 6 hours
Body Frame Mesomorph
BMI=kg/h(m)2
BMI=55kg/ (1.5748m)2
BMI= 22.17
Normal range: 18.50-24.99
Posture The patient was observed to
have postpartum posture.
Gait The patient was observed to
have some uncoordinated
movements
Coordination With patient good and carefully
coordination movement she
prevents her self-falling from
the bed.
Balance Standing stance is slightly
imbalanced as well as her
she was not able to communicate
properly in that time
2nd Assessment
The mother can communicate to us in
proper.
2nd Assessment
Due to the crying of the baby the mother
is awakened and needs to feed her baby.
2nd Assessment
Roughly 10-13 pounds is lost
immediately after birth – 7 pounds for the
baby, plus 2-3 for blood, amniotic fluid
and other.
2nd Assessment
It is normal since she is still in healing
situation and can still mild pain.
2nd Assessment
the mother cannot yet execute her
movement well because she is still
recovering
nd
2 Assessment
The mother can manage her moves in the
bed.
2nd Assessment
 walking Since the mother is still experiencing
pain and still on recovery process.
Muscle No jerky movements like 2nd Assessment
twitching and
ripples. No uncontrol muscle occur.
Motor Function
Gross 2nd Assessment

In going to comfort room the The mother movements still need

patient needs support to walk. assistance since she is in a recovery
process
nd
Fine 2 Assessment
The mother can use fork and ‘
spoon normally. the patient can be seen to use a spoon and
fork properly
Range of Motion The patient can rotate 2nd Assessment
joints, can adduct and
abduct, pronation and The assessment of the patient range of
supination of arms. motion is normal
Arms and Legs of the Patient
are the same.
Pain Relief Measures Patient sleeps when she starts 2nd Assessment
feeling minor pain.
Diversion activity to address pain
Mobility and Use of Assistive Device 2nd Assessment
Assistive device is not needed
by the patient. The mother can act without the use of
any assistive devices.

OXYGENATION
 Assessment 1st Assessment 2nd Assessment Interpretation

(October 8, 2021) (October 9, 2021)

Activity Intolerance Patient is able to care for
oneself in activities of daily
living with support or
assistance.
Nose Airway Clearance  No problem noted in
each nostril and was
able to sniff.
Patient is able to care for
oneself in activities of daily
living with support or
assistance.
 No problem noted in
each nostril and was
able to sniff.
Since the mother is still in a recovery
process, her activities are set to limit and
needs some help.
The mother has a normal airway
clearance

There is No blockages or There is No blockages or

obstruction noted
Lung Sound Loud, high-pitched bronchial
breath sounds over the trachea.
Medium pitched
bronchovesicular sounds over
the mainstream bronchi,
between the scapulae, and
below the clavicles. Soft,
breezy, low-pitched vesicular
breath sounds over most of the
peripheral lung fields.
Color  Skin: Brown in color
 Nails: Pink tones are
seen in the nails
Lips: moist without lesions or
swelling
Capillary Refill The Capillary beds refill in 1-2
seconds which is normal.
obstruction noted
Loud, high-pitched bronchial
breath sounds over the trachea.
Medium pitched The chest wall is symmetric, without
bronchovesicular sounds over deformity, and is atraumatic in
the mainstream bronchi, appearance. No tenderness is appreciated
between the scapulae, and upon palpation of the chest wall. The
below the clavicles. Soft, patient does not exhibit signs of
breezy, low-pitched vesicular respiratory distress.
breath sounds over most of the
peripheral lung fields.
 Skin: Brown in color The mother has normal skin, lips, and
 Nails: Pink tones are nails
seen in the nails
Lips: moist without lesions or
swelling
The Capillary beds refill in 1-2 the time taken for a distal capillary bed to
seconds which is normal. regain its color after pressure is normal

Pink tone returns immediately Pink tone returns immediately

 to blanched nail beds when to blanched nail beds when
pressure is released pressure is released
Peripheral Pulse Radial pulse: 85bpm Radial pulse: 85bpm 1st Assessment
 Rhythm: regular  Rhythm: regular
between intervals between intervals The mother has a normal peripheral pulse
Amplitude: equally strong in Amplitude: equally strong in assessment.
both wrists both wrists
2nd Assessment

The mother has a normal peripheral pulse

assessment.

Blood Pressure 120/80 mmHg 120/70 mmHg 1st Assessment

For a normal reading, her bp is normal

2nd Assessment

For a normal reading, her bp is normal

Edema Positive Positive 1st Assessment

 During pregnancy, edema occurs when

body fluids increase to nurture both you
and your baby and accumulate in your
tissues because of increased blood flow
and pressure of your growing uterus on
the pelvic veins and your vena cava.

2nd Assessment

The body naturally prepares

for childbirth by retaining water to help
 body tissue adapt to the baby's growth
and naturally eliminates this fluid post-
childbirth.
Homan Sign Negative Negative negative Homans' sign doesn't rule it out.

NUTRITION
Assessment 1st Assessment 2nd Assessment Interpretation

(October 8, 2021) (October 9, 2021)

Hospital Diet/ Restriction DAT (Diet as Tolerated) Refers to calculated diet plans used
Fluid Intake Since the delivery patient 2nd Assessment
drink more than 7 glasses
to compensate for the extra water that is
used to make milk. One way to help you
get the fluids you need is to drink a large
glass of water each time you breastfeed
your baby.
st
IVFs D5LRS + 10 units of oxytocin None 1 assessment

Maintenance of body fluids and nutrition,

and for rehydration.

improve contractions during labor and

prevent postpartum hemorrhage.

Height 5’2 (1.5748 m)

Weight 55kg 2nd Assessment
 Since the exclusion of fetus, placenta and
amniotic fluid caused the loss weight

Skin Turgor As we pinch the clients As we pinch the clients

skin turgor goes back skin turgor goes The patient is not dehydrated
immediately to its back immediately to
original state after its original state
pinching after pinching

Ability to:
Chew The Patient is able to bite and it is Normal
chew
Swallow The patient can swallow and it is Normal
digest
Feed Self The patient is independent in it is Normal
feeding herself.