13 AREAS OF ASSESSMENT
PATIENT'S NAME: CHAPYOSEN, FELIDA
Dx: Avulsed wound right leg secondary to dog bite category 3 Upper respiratory tract
infection to consider CAP
I. PSYCHOSOCIAL AND PSYCHOLOGICAL STATUS
Patient X is a 82-year-old female, widowed and a farmer, a Roman Catholic and
born in January 1, 1941 at Bontoc Mountain province. Patient x is Kankanaey-Bontoc
dialect and from Omfeg, Bontoc. Her family belongs to the middle class. Erik Erickson's
Stages of Psychosocial Development indicates the patient falls under Ego Integrity vs
Despair.
II. MENTAL AND EMOTIONAL FEELINGS
Patient X is conscious, alert, coherent and oriented as we receive her awake
responds immediately and fully to commands with score of 13 /15 in Glasgow coma
scale (E=3, M=6, V=4). She is 82-year-old female and is working as a farmer. During the
assessment, Patient x is well oriented to her surroundings as she knows the current time
and date and her location. She is very cooperative in nursing care. No social fear or
concern were noted and no medications or substances were taken to alter emotional
response. She verbalized that she is not stressed but very bored.
III. ENVIRONMENTAL STATUS
Patient X, age 83 is currently living in Omfeg, Bontoc in her house alone. The house is
concrete. There is steady pattern of activity, light noise in her environment and it does
not distract her . She is comfortable during sleep. The food and water are on her side
table and is placed at the left side of the patient it is accessible for her needs. Patient is
in the female surgical ward, together with her daughter.
IV. SENSORY STATUS
A. Visual Status
Patient’s eyes are round in shape, dark brown with bluish in color, sclera is white,
conjunctiva is pink and moist. Presence of cataract noted. Eyelashes are evenly
distributed. Patient's eye were able to move in full range of motion as her eyes follow
the six cardinal positions. Also, her pupils constrict when exposed to light.
B. Auditory Status
When it is near patient was able to distinguish voices, but when it is far
patient were not able to distinguish the voice. As a whisper test was conducted
patient x can repeat some words on her both ears. She also stated that she had
no history of ear infections but there is strange sensation like ringing and buzzing.
As per that there are no known deficits and no corrective devices noted being
used by the patient.
C. Olfactory Status
There are no disparities in the nose's size and shape of the patient. Also,
during the assessment there were no discharge found. The client was able to
distinguish the smell of alcohol, it signifies that there are no obstructions or
abnormalities.
D. Gustatory Status
Patient's lip are brownish in color and moist and symmetrical in shape. The
tongue is light in color as it is pink and is wearing a complete set of dentures.
Also, patient was able to differentiate both flavors and correctly identify the
samples as the client tasted a pinch of salt and sugar with her eyes closed.
E. Tactile Status
For this test, the patient was asked to close her eyes and a cotton bud that
the student nurse cut in half was used to randomly stroke her forehead to
introduce sharp and dull sensation, and she was partially distinguish the sharp
and dull ends. Patient x also able to differentiate common objects by touching it
such as ballpen and nailcutter and able to recognize some of letter that is drawn
on her skin.
F. Language Perception and Formation
Patient x, age 82 with highest educational attainment of elementary. By
assessing the client her speech organs are intact and have no deficit in
phonation. As we are interviewing the patient, she was not able to understand
all of the instruction given to her in conducting the assessment and needed her
daughter to translate the instruction in their mother tongue.
V. MOTOR STATUS
Motor strength is assessed. Her movements are limited since their is IV line on
her left dorsal venous network and on her right leg their is a presence of suture
due to dog bite. The patient was able to move and can move all her joints slowly
and carefully as of the moment. She verbalized that her daughter can assist her
whenever she needs something.
VI. TEMPERATURE STATUS
Upon receiving the client, her temperature is 35.9 degree Celsius. There is no
signs of profuse sweating or even irritated. The environment is adequately
ventilated.
DATE TIME TEMPERATURE
Initial Vital Signs 8:00 AM 35.9
November 13, 2023
10:00 AM 36.3
2:00 PM 36.5
6:00 PM 36.2
VII. RESPIRATORY STATUS
Upon receiving patient, she is awake and responds immediately and fully to
commands, there is no observed use of accessory muscle and with each respiration
the chest wall expands symmetrically with no visible retractions. Also, the patient has
no history of smoking and taking any medication.
DATE TIME RESPIRATORY RATE
Initial Vital Signs 8:00 AM 19
November 13, 2023
10:00 AM 21
2:00 PM 20
6:00 PM 21
VIII. CIRCULATORY STATUS
Upon receiving the client, there is no visible signs of cyanosis. The obtained pulse rate is
48 bpm and capillary refill of three seconds, having blood pressure of 130/90 mmHg.
DATE TIME HEART RATE
Initial Vital Signs 8:00 AM 48
November 13, 2023
10:00 AM 45
2:00 PM 49
6:00 PM 52
IX. NUTRITIONAL STATUS
The patient food is being served in the hospital and she is in Regular Diet. Their is
no change in the appetite in eating during the hospitalization. The patient is wearing a
complete set of dentures. The skin is dry and with brownish color. The nails were fine but
not well trimmed. There is no culture or religious dietary restriction reported by the
patient. The patient is able to swallow her food and medications as well. The patient
denied any indigestion and vomiting . The patient is eating orally by herself.
X. ELIMINATION STATUS
The patient eliminates in a toilet bowl once a day. The stool is usually brownish
and semi-solid. The patient state that there is no change in her urine and stool output.
She frequently urinates before and during her stay at the hospital. She urinated 1-3
times during my shift. The patient claimed absence of special problem like urinary and
bowel retention, urinary incontinence and diarrhea.
XI. SLEEP, REST AND COMFORT STATUS
Prior to hospitalization, the patient stated that she rest and sleep about 6-8 hours
a day. She verbalized “makaturog ak met tas makainana ken hannak madidisturbo nu
maturog ak" During assessment, she also stated that she was able to sleep well at night
but sometimes being disturbed when nurses have to get her vital signs or give
medication. She can also sleep 6-8 hours during hospitalization and takes a nap at day
time as she feels sleepy. Patient x stated that she is comfortable on the bed but
sometimes gets uncomfortable when she lays on bed for too long when awake.
XII. FLUID AND ELECTROLYTES
The patient usually drinks 5-6 glasses only of water daily and urinates regularly.
She has an ongoing IVF of PLRS 1L x 12 hour regulated at 20 to 21 gtts/min. With a skin
turgor of 3 seconds and has a dry and soggy skin. Within three seconds, the patient's
capillary refill returns to normal. Presence of edema noted on both legs.
XIII. INTEGUMENTARY STATUS
Skin color is brownish with a skin turgor of three seconds. Presence of wound on
the right leg due to dog bite category three with intact and minimal bleeding on
dressing over the wound site. No history of skin allergies, no tattoos, bed sores and also
her skin is cold to touch. There is also a presence of swelling on the IV site. She has a mid
length, black with visible white hair due to old age, thin and evenly distributed hair that
doesn't have any dandruff or any parasites like lice.
