Appraisal and Assessment (CHI. Assessment?A process that integrates test information with information from other sources…
Assessment of patient
Received female patient in bed in the left lateral position in no form of respiratory distress. Patient voiced abdominal pain and headache. O/E: Patient was alert and rationale. Oriented to person, time and place. Skin was of a dark brown complexion. Skin appears moist and well hydrated. Bilateral pedal edema noted. Nails were clean and well groomed, normal pink striation seen. Capillary refill was less than one second.
Hair is evenly distributed and well kept. On palpation of the head no palpable mass or tenderness elicited. Face orifices was clean. Chest expansion equal and adequate. Normal breath sounds were heard over the lung field. Respiration rate of 20 breathes per minute. No sign of raise Jugular vein seen. Normal SSL and so sounds were heard. Pulses were palpable bilaterally except the carotid pulse. Pulse rate of 88 beats per minute of a regular rhythm and pattern.
Blood pressure of 124/81. Abdomen was obese with normal striations seen. Lineal Niagara located In the midlines of abdomen from the synthesis pubis to the umbilicus. Umbilicus is In the midlines of abdomen no redness or discharge seen. Uterus is gravid. Fetal heart rate was 134 beats per minute. Bowel sounds were heard on auscultation. Abdomen was firm with a fungal height of 36/ 40 weeks. Per vaginal loss was minimal creamers discharge. Full range of motion to extremities.