HEAD TO TOE ASSESSMENT POSTPARTUM:

Respiratory: Lungs clear to auscultation with sounds equal bilaterally. Respirations are regular and non-labored with 16 per minute.
Cardiovascular: oral temperature is 98.2° Fahrenheit (36.2° C), peripheral pulses palpable x 4, apical heart rate of 117 beats per minute with a regular rhythm. BP :153/84 sitting, cap refill <3 seconds, skin warm pink and dry, Homans (-), Lochia = 2 small amount rubra in color, Edema = +1 in lower extremities. 
Breasts: Breasts are soft and tender, nipples are intact, feeding = bottle. 
Pain Score: 5 resting increasing to a 7 with movement at abdominal incision site.  (on a scale of 1-10), patient reports a headache in the neck and back of head.
Musculoskeletal: Moves all extremities without difficulty, no assistance needed with activity.
Neurological: Alert and oriented to person, place, and time, speech clear and appropriate, PERRLA. 
Urinary: patient voids on own without difficulty. 
Abdominal/Gastrointestinal: BSx4 quad normoactive, no BM in two days, patient states “this is normal for me”, fundus is firm at umbilicus, abdomen is soft and non-distended with pain reported at the incision site, incision is intact without edema, ecchymosis or drainage, sutures intact. 
Emotional support: Patient show signs of anxiety and guilt. Patient states:  “I am worried about my baby” patient asks doctor “If I hadn’t has the baby early would she be alright”, Patient states, “all I want to do is see my daughter but they won’t let me leave the hospital.” and “have been on medication for blood pressure since 2002 and have never had to see a cardiologist before”, “I don’t understand why they keep changing my medicine, the ones I was on before I got pregnant seemed to work, these new ones are not
Working.”