CANETE

General Appearance
- Patient moves listlessly and with cringing expression although states that pain is tolerable.
The patient has not combed hair nor have changed clothes since last night which signifies
exhaustion from labor and delivery.

Face
- There is no evidence of edema, although patient has puffy eyelids brought about by sleeping
in a supine position with her head leveled.

Breast
- The patients breasts upon palpation is soft and the nipple is erect although the patient
complains that there is only a little amount of milk production

Uterus
- The patient’s uterus is firm upon palpation, fundal height is 1 cm below the umbilicus.

Lochia
- Lochia discharge is dark red in color and minimal in amount which is Lochia Rubra; odor is
not foul in smell; 2 diaper changes a day

Perineum
- Perineum is tender upon palpation, with no hardened areas. Episiotomy wound still fresh
and a bit painful as stated by the client; perineal care involves use of feminine wash and
water

EVIOTE

General Appearance
- Patient is able to accomplish tasks quickly such as moving the baby or moving her hands
during vital signs assessment.

Face
- Patient has no evidence of edema but has visible puffy eyelids due to lack of sleep.

Breast
- The patients breast upon palpation is firm and warm which signifies filling and the nipple is
erect

Uterus
- The patient’s uterus is firm upon palpation, fundal height is approximately 2 cm below the
umbilicus.

Lochia
 - Lochia discharge is red in color and minimal in amount which is Lochia Rubra (droplets, as
stated by the patient); odor is not foul in smell; does not use diaper or perineum pads
anymore

Perineum
- Perineum is tender upon palpation with no hardened areas or presence of hematomas;
perineal care involves use of soap and water.