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    Safran, Jayrelle Aldrin Shayne D. - Act # 1.5 Finals (7th Rotation)

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    Jayrelle D. Safran
    The student observed and assessed a patient in labor and delivery over multiple dates. The physical examination showed the patient appeared well overall, with intact skin and normal features of the head, eyes, ears, mouth, throat, nose, heart, abdomen, extremities, genitals, and neurologic system. The patient was experiencing contractions but no other abnormalities were noted.

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    Safran, Jayrelle Aldrin Shayne D. - Act # 1.5 Finals (7th Rotation)

    Uploaded by

    Jayrelle D. Safran
    61 views1 page
    The student observed and assessed a patient in labor and delivery over multiple dates. The physical examination showed the patient appeared well overall, with intact skin and normal features of the head, eyes, ears, mouth, throat, nose, heart, abdomen, extremities, genitals, and neurologic system. The patient was experiencing contractions but no other abnormalities were noted.

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    The student observed and assessed a patient in labor and delivery over multiple dates. The physical examination showed the patient appeared well overall, with intact skin and normal features of the head, eyes, ears, mouth, throat, nose, heart, abdomen, extremities, genitals, and neurologic system. The patient was experiencing contractions but no other abnormalities were noted.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    61 views1 page

    Safran, Jayrelle Aldrin Shayne D. - Act # 1.5 Finals (7th Rotation)

    Uploaded by

    Jayrelle D. Safran
    The student observed and assessed a patient in labor and delivery over multiple dates. The physical examination showed the patient appeared well overall, with intact skin and normal features of the head, eyes, ears, mouth, throat, nose, heart, abdomen, extremities, genitals, and neurologic system. The patient was experiencing contractions but no other abnormalities were noted.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    LORMA COLLEGES CON TEMPLATE

    PHYSICAL EXAMINATION
    RELATED LEARNING EXPERIENCE

    AREA: Labor Room and Delivery


    th
    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

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