Shehada Bondad
BSN-4
THIRTEEN AREAS OF ASSESSMENT
I. Psychological
Mrs X is a 44 year-old female and married. She lives with her
parents and presently residing at #555 Lower Quirino Hill, Baguio City.
She is very independent in terms of her health to her mother and other
health care professionals. The patient and her family is Roman Catholic
and have no practices or beliefs which might affect to providing health
care. Watching the television, eating and singing is her way in spending
her leisure time. She has positive outlook with her life.
II. Mental and Emotional Status
With regards to her level of consciousness, she is alert and
responds a wide range of stimuli. She has a good intellectual
development. She can easily understand and follow instructionsand has
the ability to comprehend. She has a good emotional intelligence as
manifested an appropriate emotional response to stimuli or situation.
During the interview, he is able to express his
feelings and uses clear words
During the interview, he is able to express his
feelings and uses clear words
During the interview, he is able to express his
feelings and uses clear words
During the interview, he is able to express his
feelings and uses clear words
She's got a strong perception about her wellbeing. She is very cooperative
and prevents her health from being further affected by such activities. No
societal problems or worries have been identified and no medications or
drugs have been taken to alter the emotional response.
III. Environment Status
She has an appropriate state of mobility to his age and aware of the
potential danger hazard. She has no sensory deficit and is properly
oriented to time and place. Patient and family membershas no any
history of any infectious disease. In her setting, there is a steady activity
pattern, light noise and color, and it does not disturb her. She feels
relaxed when sleeping. The food and water or other necessities is put on
the patient's left side table and is available for her needs..
IV. Sensory Status
In visual activity she has the ability to distinguish objects. She’s not
using any corrective device. She can determine different voices. In the
olfactory status, she can distinguish odors. She is able to distinguish
foul smelling odors andaromatic odors. In gustatory status, she has the
ability to make a distinction between sweet, sour, salty and bitter foods.
Intactile status, she can discern rough and smooth things. She has
intact speech organs; the mouth, teeth, palate and larynx.
V. Motor Status
In general, all body parts are well coordinated and she can move with
ease, however limited ROM was noted when in pain due to surgery
procedure.
VI. Nutritional Status
Prior to admission, patient consumes full meal 3x a day. She eats
meals on time and a balanced diet. The appetite for food during
hospitalization and the deviation in health is not affected. Without dental
carriages, teeth are full. The skin is brownish and shiny. The clots were
good and fine cut. The patient does not disclose any cultural or religious
food restriction. In her diet and medicine, the patient is still able to
consume. The patient denied any vomiting or indigestion. The patient
feeds by herself orally.
VII. Elimination Status
The patient eliminates in a toilet bowl once a day. The stool is
usually brownish and semi solid. He drinks water to aid her elimination.
There is change in her out put. She verbalized that she frequently
urinates during her stay at the hospital. She urinated 1-2 times during
my shift. She usually consumes 5-6 or more glasses of water per day.
The patient claimed absence of special problem like urinary and bowel
retention, urinary incontinence and diarrhea. Patient denies feeling of
thirst.
VIII. Fluid and Electrolyte Status
Prior to admission, she has a good skin turgor that indicates good
hydration. She usually consumes 3L of fluid a day and urinates
regularly. She has no signs of dehydration and fluid overload.
IX. Circulatory status
The blood pressure upon admission is 130/100 mmHg, during the
shift the BP when standing and sitting was 120/90 mmHg. She has a
normal ventricular refill with no heart murmurs as per auscultation.
During the shift, the pulse rate is 68 beats per minute, which is in the
normal range. In terms of emotional tension and physical activity, the
pulse rate is rising.
X. Respiratory status
She had a normal respiratory status of 21 cpm. No abnormal signs
heard upon auscultation. There is no signs of any respiratory distress.
XI, Temperature Status
Patient’s body temperature is within normal range of 36 °C-36.8°C.
Sh manifested no chills, sweating or any signs of altered
thermoregulatory status. Patient uses blanket when feeling cold and
remove excess clothes when feeling hot due to environmental changes.
XII. Integumentary Status
The dressing is dry and intact and sometimes painful. Nails and hair
are well kept by the patient. There are no odorous secretions or oily
secretions. Upon physical assessment of the client, there was presence of
marks/scars of wounds in the arms and legs. Skin is smooth, moist and
soft to touch.
XIII. Comfort and Rest Status
The patient says that she usually sleeps for eight to ten hours a
day. Her sleep during her hospitalization was now just 6-7 hours. She
says that even though she is in her ward, she's very relaxed with her
sleep, but often interrupted when nurses get their vital signs or send her
medications.
