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Summer Project in h.a.

Summer Project in h.a.

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Published by: Danna Christine Gumboc Paguntalan on Jun 30, 2011
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13 Areas of Assessment I. Social Status Demographic Data Mr.

E is a 25 year old male, born on April 27, 1986 via NSVD by a “hilot”. He is the youngest of the 3 siblings. The family resides in Igbaras, Iloilo. He is still studying at University of Iloilo PHINMA taking up Bachelor of Science in Nursing.

Socio-Economic Factor Mr. E belongs in a nuclear family, Roman Catholic and a student. His father is a retired employee of Universal Distillery Company and his mother is a housewife with a family income of 20,000 pesos per month which according to Mr. E is enough to meet their basic needs. He has a sister and a brother which have a family already.

Environmental Factor Mr. E resides in a 2 storey medium size house with a 5 stairs going up to the second floor without railings, made up of concrete with 4 rooms and 1 bathroom with good ventilation. The house is located in a residential area. According to Mr. E they are buying their water for drinking and motor pump is their source of water for washing, bathing and laundry purposes. Their excreta disposal is water sealed. The family of Mr. E owns a pet dog with a regular vaccination of anti-rabies.

Erick Erickson’s Psychosocial Theory Based on Erickson’s psychosocial theory Mr. E a young adult is classified under intimacy vs. isolation which explains that most important event are love relationships no matter how successful a person are. He is not developmentally complete until he is capable of intimacy on the other hand, an individual who has not yet developed a sense of identity usually will fear a committed relationship and may repeat to isolation. In Mr. E’s case, he had 3 relationships but now he chooses to be single and focus himself with his family and his studies.

II. Mental Status Mr. E is conscious and coherent, oriented to person, place and time. He is a college student, able to maintain eye to eye contact. He is open and approachable and is able to converse with the student nurse.


III. E is close with his family and if ever he has a problem he opens it to his parents and siblings. Mr. I ask him to identify the two samples by smelling. Hearing 2 .During Assessment Mr. and his eyes were able to move in full range of motion and in all directions. E is a Roman Catholic. Before the next procedure. rises are black in color. according to the patient. Eyes are almond in shape. without the patient’s knowledge. he went to church and attend the mass every Sunday this implies to him that he have faith in God and trust his life to Him. Mr. Pupils are equally round and reactive to light accommodation. His conjunctiva is pale and moist. Patient is also instructed to follow the direction of a finger with his eyes following six cardinal positions. Test shows that there are no abnormalities or obstructions were identified in the sense of smell. and scleras are whitish in color. Smell Client’s nose has no deviation in terms of shape and size. nose is pointed and no discharges were seen during assessment. E. E was able to share past experiences about his childhood and past relationship showing that his long term memories are still intact. patient is instructed to look straight to observe the general appearance of his eyes. Sensory Perception Vision In assessing the vision. Visual acuity is assessed by asking the patient to read the word written in a piece of paper with a font size of 12 about 3 feet away from him using the right eye first then left eye and then both eyes. The patient does not use eyeglasses or contact lenses. he doesn’t have any history of sinus infection or epistaxis. eyebrows and eyelashes are equally distributed. permission was asked to the patient to do another test. he is very cheerful.Emotional Status According to Mr. After smelling he correctly identified the two fruits. funny and has a sense of humour. He is friendly and has lots of friends in their place. using a peeled apple and the skin of an orange. IV. With the use of a penlight pupils are assessed.

no dentures and has 4 teeth loss. and he stated that he felt a sensation of wet and cold on his skin. No inflammation. In assessing the hearing acuity of the patient. tenderness and deformity upon palpation of joints. I poured an alcohol on it and rubbed it on the same area. E’s ears were parallel. After the test Mr. 2 at the upper portion and 2 at the lower portion of the teeth. bean shaped.O. He performed it with ease with the muscle grade of 5+ which is normal. symmetrically proportional to the size of head. E is instructed to repeat the words that will be whispered at a distance of two feet away on the left ear first. a cotton ball was stroke to the back of her neck. but there is a presence of tooth cavities. E’s sense of touch. E’s lips were moist and symmetrical in shape. patient is asked to do some test. E identified the two samples correctly. he was able to repeat the whispered words. He was asked to taste a pinch of sugar and a pinch of iodized salt without knowing the two samples are. E he was able to exercise such as jogging and weight lifting if there is no class and if he has time. buccal area are moist. Taste Mr. Mr. Touch In assessing Mr. VI. V.M. then using another cotton ball. no presence of tooth decay. another test by the use of the beeping sound of our electronic thermometer at a distance of 4 feet away and still he was able to hear the sound. he was asked to close his eyes. To assess her sense of taste. He performed it with ease and freely moves without any difficulty. He can bend and straightened her elbows and extend and spread fingers. firm cartilage and with a presence of cerumen. He was asked to raise both his arms.General appearance of Mr. then right ear after the test. Using the case of BP apparatus which is rough in texture and the medical kit which is smooth in texture. he correctly identified the difference of two materials. Motor Ability Patient is asked to perform R. Temperature Date Time Temperature Location 3 . After the test. no signs of gingivitis. tongue in pinkish color. According to Mr. exercises on the upper and lower extremities. I assess using a tongue depressor. the patient is asked to touch the two materials and ask the texture while blindfolded.

He is a non-smoker and occasional alcoholic drinker maximum of two bottles of beer. no adventitious breath sounds were heard. No scars. He has a good appetite and don’t have any special diet. During auscultation 15 bowel sounds per minute were heard this implies audible and normal bowel sounds. lumps and tenderness. 4 .9°C May 17. after auscultation. VIII. Nutritional Status Mr. pulse scale is 2+ which is easily palpable. his capillary refill is within 1 to 2 seconds taken at right forefinger. negative for peripheral edema. Respiratory Status Date May 17. IX. 2011 Time 3pm PR in Beats per minute 84 Pulse is regular in rate and rhythm taken at radial pulse. 2011 Time 3pm BP 120/80 mmHg Taken at her brachial artery. Blood Pressure Date May 17. No masses. E is afebrile and temperature is at 37. VII.1°C taken at right axilla. Rhythm and respiration pattern are regular. No supraclavicular or suprasternal retractions were seen during inspiration. E stated “Kung sa school karne gid sud-an ko pirme. Nailbeds and palms are pinkish in color and no presence of edema. He has an effective airway clearance and effective breathing pattern which provide adequate gas exchange and results to a good level of consciousness. Circulatory Status Date May 17. Lungs were auscultated for adventitious breath sounds. lesions and masses upon inspection and palpation of the abdomen. 2011 Time 3pm RR in Cycle per minute 18 His chest expansion was symmetrical with ease during respiration.”He drinks about 2 liters of water a day and a cup of cereal drink for breakfast.36. 2011 3pm Axilla Mr. pero sa balay gulay kag sabaw.

no bed sore. He urinates 8 times a day approximately 60cc per urination according to Mr. after bathing he apply lotion in his skin and uses deodorant. E’s statement. Nail During assessment nails are pinkish in color. Urine is sometimes amber or straw in color. He uses 5 pillows. Elimination Status Mr. sleeps 8 hours a day before going to sleep he take a sponge bath and never fails to always say a prayer before going to sleep.5 kg 1. He sleeps at around 9pm during weekdays and 11pm during weekends. XI. Skin Mr. one at his head and 2 on each side. Reproductive System According to Mr. He takes a bath everyday he uses shampoo and soap for bathing. and no skin lesions. Physical Rest and Comfort Mr. Patient has history of skin allergy which effect from his past medication which is cefazolin this can cause to him itchiness all over the body and narrowing of airways. E he had his circumcision when he was 11 years old. Patient has a dark complexion. 5 . E has good skin turgor. no presence of tattoo. no signs of clubbing. no lice and ticks.57m2 = 23. E stated that he defecates once a day every morning before taking a bath with a semi-solid consistency without difficulty. XII. patient has short straight hair. E. XIII.Patient’s BMI 57. State of Skin and Appendages Hair During assessment there was no dandruff seen. he also undergone appendectomy which leaves a 5 stitches scar within the right iliac region according to the patient. Patient has good capillary refill which is 1 to 2 seconds.37 (normal) X. urine output of 480cc a day.

after the test. the patient was asked to do self breast examination. masses and tenderness and no enlargement of thyroid gland. Extremities The patient was assessed for Homan’s Signs. According to the patient he doesn’t feel any masses and lumps in his breast. patient did not feel any calf pain and he don’t have any signs of thrombophebitis and edema in the lower extremities. Neck Patient has no enlargement of lymph nodes nor pain or stiffness. During inspection breast is flesh colored. his legs were dorsiflexed.Breast In assessing the breast. During auscultation no sound heard in the thyroid gland area same with carotid arteries no swishing heard upon auscultation. drape was provided for the patient privacy. Pain No pain during assessment. nipples and areola is brownish in color. 6 . Lymph nodes and axillary lymph nodes are not palpable.

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