LORMA COLLEGES CON TEMPLATE

PHYSICAL EXAMINATION
RELATED LEARNING EXPERIENCE

AREA: Labor Room and Delivery

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STUDENT NAME: Safran, Jayrelle Aldrin Shayne D. ROTATION: 7 Rotation Room
DATES: DECEMBER CLINICAL INSTRUCTOR: ROWENA
YR LEVEL AND SEC: BSN II – Nightingale 9,10,11,16,17,18, 2021 HENSON

A. GENERAL ASSESSMENT

 Appears well, contractions make her feel uncomfortable

B. SKIN, HAIR AND NAILS

 Skin is intact, nil bruises, pressure sore or skin tear noted. Hair is shiny, long and black. Nails are smooth, nil pits
or grooves.

C. HEAD AND NECK

 Head is normal in size, nil signs of lumps and skin irritations.

D. EYES AND EARS

 Eyes are symmetrical, nil signs of redness and any abnormal discharges.
 Ears are free from excessive wax.

E. MOUTH, THROAT, NOSE AND SINUSES

 Mouth, throat, nose and sinuses are normal. Nil signs of inflammation and redness

F. HEART AND NECK VESSELS

 Heart rate and sound are normal. Nil sounds of murmur. Nil signs of jugular vein distention.

G. ABDOMINAL ASSESSMENT

 Linea nigra and striae gravidarum noted. No abnormal distension noted. Fundal height within normal
parameters

H. EXTREMITIES

 Extremities are symmetrical, nil signs of malformation

J. GENITALIA

 Genitalia appears normal. Nil skin irritations or rashes present. Nil abnormal discharges

I. NEUROLOGIC

 GCS 15, patient is oriented, alert and coherent