Saint Mary’s University

SCHOOL OF HEALTH and NATURAL SCIENCES

Nursing Department
Bayombong, Nueva Vizcaya

Chapter V. Physical Assessment and Physiological Basis

Psychosocial

Assessment 1st Assessment

October 24, 2022
Significant others Mr. RT, 29 years old, husband of Mrs. MHT and the one who
brought and assisted her in having prenatal checkups
Coping Mechanism Coping mechanisms of the mother are:

Meditation: When she is alone, she reflects on what must be

done and anticipates the labor process and the rearing of her
future newborn.

Exercise or Distractions: Activities such as walking and talking

to others.

Conscious release: Tensing and relaxing different parts of her

body allowing her to learn to isolate tension in one muscle
group while tensing others.

Guided Imagery or visualization: Allows the mother to imagine

Structure of the Family
Religion
Primary Language
Primary Source of Health
Care
Financial Resources to Illness
Educational Attainment
General Appearance
things that enable her to respond with relaxation
Nuclear
The patient stated that they are members of Pentecost
The patient stated her primary language is Tagalog, because it
is the dominant language used by her parents when raising
her.
Villaverde, Barangay Health Center and the Region 2 Trauma
and Medical Center (R2TMC)
None
The patient is an Elementary graduate
The client seems to be the 33-year-old client she claims to be
and she is appropriately dressed for her age and the occasion.

The client displays good posture, able to maintain eye contact.

Orientation Mrs. MHT is completely aware of both her own self and
exterior reality, as evidenced by her ability to recognise herself
and the time, place, and self with whom she is speaking. In
addition, the orientation of her body is dictated by external
stimulants such as light, gravity, or other visible elements.
Memory The memory of the client is functioning well to recall both long-
and short-term memory. However, there are times that she
forgets information
Speech The speech pattern of the client, Mrs. MHT is normal and clear
Nonverbal Behavior Mrs. MHT portrays appropriate facial expression and maintain
good and respective eye contact

1st Floor, Constant Jurgens (UB) Building

Saint Mary’s University, Ponce St., Bayombong, Nueva Vizcaya, 3700 Philippines
Telephone: (078) 321-2221 ext. 122; Telefax: (078) 321-2117; Mobile No.: 0936-286-7269
 Saint Mary’s University
SCHOOL OF HEALTH and NATURAL SCIENCES
Nursing Department
Bayombong, Nueva Vizcaya

Rest and Activity

Assessment 1st Assessment

October 24, 2022
Current Activity Level The patient can do any activity that doesn’t involve any
activities that require too much strength especially lifting heavy
objects
ADLs Grooming - the patient can take a bath or shower on her own,
comb her hair and make herself presentable.

Feeding - the patient can cook and feed herself independently

Toileting- independent

Dressing - the patient can independently dress herself.

Communicating - the patient can communicate clearly and

effectively
Sleep Mrs. MHT wakes up around 5:30 AM when her child has
classes, and her husband is not around since she cooks their
breakfast and walks her child to school. Sometimes she wakes
up at 6:00 and usually sleeps at 7:00 PM.
Body Frame The BMI of the patient is 25.9 kg/m2 and her body frame is
mesomorph

Posture Standing- lordotic.

Sitting- slightly leaning forward. Shoulders in the back ,

buttocks is touching the back of the chair
Gait Waddling gait, in a complete two cycle of both feet in contact
to the floor with the same normal speed.
Coordination The patient has good coordination
Balance The patient has a good balance.
Range of Motion Arms - the arms of the patient can extend, abduct, adduct,
pronated and supinated.

Elbows - both of the elbow of the patient has a full resistance.

Wrist- both wrists of the patient are able to bend down and
back.

Hands and fingers- both hands of the patient can be able to

move and her fingers can close and open.

Knee- the patient can bend, extend and flex her both knees
Patient Relief Measures Mrs. MHT rests through lying down and sleeping
Mobility and use of ability Mrs. MHT is not using any assistive devices
device

1st Floor, Constant Jurgens (UB) Building

Saint Mary’s University, Ponce St., Bayombong, Nueva Vizcaya, 3700 Philippines
Telephone: (078) 321-2221 ext. 122; Telefax: (078) 321-2117; Mobile No.: 0936-286-7269
 Saint Mary’s University
SCHOOL OF HEALTH and NATURAL SCIENCES
Nursing Department
Bayombong, Nueva Vizcaya

Safe Environment

Safe Environment 1st Assessment

October 24, 2022
Allergies/ reaction Medication- the mother has no medication allergies or
reaction.

Food- there are no food allergies or reactions.

Environment - the mother has no allergies or adverse

reactions to the environment
Eyes/ vision The mother doesn’t have any problem in her eyes or vision.
Her eyes are still good in sight
Hearing aid Mrs. MHT doesn’t use hearing aids
Skin Integrity Good skin integrity. Skin is moist and without rashes.
Presence of striae gravidarum and linea nigra in the abdomen.
Surgical Incision None
Mucous Membrane The mucous membrane of the mother is moist with clear pink
discharge
Temperature 36.7°C (Normal)

Oxygenation

Oxygenation 1st Assessment

October 24, 2022
Activity Intolerance Mrs. MHT can still perform her basic activities of daily living
(BADL) without feeling excessive fatigue.
Airway Clearance The patient’s airway was clear as evidenced by her normal
lung sound, and she could sniff in each nostril and there was
no occlusion noted nor blockage or obstruction.
Lung Sound Regular beat and 19 breaths per minute. She has broncho
vesicular sounds with a medium pitch across the major stem
bronchi, between the scapulae, and below the clavicles. There
are no audible sounds such as crackles or wheezes indicating
abnormalities.
Skin Color Skin: Type 4 (olive moderate brown) with no signs or
abnormalities
Capillary Refill The patient’s Capillary Refill is normal when the blanching test
is performed, the region becomes white when squeezed;
remove the pressure, and the area turns pink in one second.
When pressure is relaxed, the pink tone returns to the
blanched nail beds instantly
Blood Pressure 100/70 mmHg

Nutrition

Nutrition 1st Assessment

October 24, 2022
Diet Mrs. MHT eats lots of fruits especially apple, citrus and
grapes. Mrs. MHT usually eats three times a day before, but
now she usually eats five times a day during her pregnancy.
Fluid Intake Mrs. MHT drinks a lot of water, at least eight to ten glasses of

1st Floor, Constant Jurgens (UB) Building

Saint Mary’s University, Ponce St., Bayombong, Nueva Vizcaya, 3700 Philippines
Telephone: (078) 321-2221 ext. 122; Telefax: (078) 321-2117; Mobile No.: 0936-286-7269
 Saint Mary’s University
SCHOOL OF HEALTH and NATURAL SCIENCES
Nursing Department
Bayombong, Nueva Vizcaya

water daily. She doesn’t crave anything however she eats junk
foods and drinks soft drinks sometimes. Her attending OB
recommended her to drink milk, but she doesn’t like the taste
of it which is why she drinks coco without sugar.
Skin Turgor Mrs. MHT has a good skin turgor, normal capillary refill.
Height 144.5 cm (4’7”)
Weight 54 kg
BMI 25.9 kg/m2
Ability to Mrs. MHT can chew and swallow foods. Also, she's able to
- Chew feed herself.
- Swallow
- Feed self

1st Floor, Constant Jurgens (UB) Building

Saint Mary’s University, Ponce St., Bayombong, Nueva Vizcaya, 3700 Philippines
Telephone: (078) 321-2221 ext. 122; Telefax: (078) 321-2117; Mobile No.: 0936-286-7269