Chapter III

13 Areas of Assessment

I. Social Status

Patient X is a 82 year-old female and widowed. She

lives with her son and presently residing at Baguio

City. She is very dependent in terms of her health to

her children and other health care professionals. The

patient and her family is a Christian 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

The patient is conscious, alert and coherent. She is not

really that responsive in verbal stimuli because of

difficulty in hearing to sounds but is responsive to noise,

light, touch and pain stimuli. She is oriented to current

time, date and place. She acts according to her age. She

has good perception about her health. She is very

cooperative and prevents somethings to further cause

damage to her health. The patient responded not that

interested on the questions I asked. No social

concerns or fears were noted and no medicines or

substances were taken to alter emotional response. She

verbalized that she is not stressed but very bored.

III. Environment Status

There are no sensory deficits and she is oriented that

she is in the hospital. Patient is knowledgeable about

her conditions. There is steady pattern of activity, light

noise and color in her environment and it does not distract

her. She is comfortable during sleep. The food and water or

side table is placed at the left side of the patient it is

accessible for her needs. Patient is in the medical ward,

together with her son.

IV. Sensory Status

There is no known visual deficit like color blindness. She

cannot distinguish voice from a distance, loud or soft

because of difficulty in hearing sounds. No auditory

device noted being used by the patient. The patient is

able to discriminate an odor from the other. The patient is

able to discriminate sweet, sour, salty and bitter

tastes from each other. With regards to the patient’s

tactile status, she was able to determine that the patient

is able to discriminate sharp and dull, light and firm

touch, able to perceive heat, cold, pain in proportion

to stimulus, able to differentiate common objects by

touch by doing necessary procedure.

V. Motor Status

Motor strength is assessed. Her movements are limited

because of her age.The patient is able to move and can move

all her joints slowly and carefully as of the moment.. No

prosthetic device was noted present with the patient

and all her extremities are intact. She verbalized that

her son can assist her whenever she needs something

VI. Nutritional Status

The patient food is being served in the hospital and she is

in DAT. The patient appetite Is good. There is no change in

the appetite in eating during the hospitalization and

health deviation. Teeth are incomplete. The skin is smooth

and with brownish color. The nails were fine and well-

trimmed. There is no culture or religious dietary

restriction reported by the patient. The patient is

able to swallow in her food and medications as well.

The patient denied any indigestion, vomiting. The patient

is eating orally by herself.

VII. Elimination Status

The patient eliminates in a toilet bowl once a day. The

stool is usually brownish and semisolid. She drinks water

to aid her elimination. She verbalized that she frequently

urinates during her stay at the hospital. She urinated

1-2 times during my shift. She usually consumes 2-3 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

The patient usually drinks 2-3 glasses only of water daily

and urinates regularly. The patient denies the feeling

of thirst. Her skin turgor is above 3 seconds because of

age realted and she has moist mouth and mucous membranes.

The patient’s capillary refill is 1-2 seconds.

IX. Circulatory status

The pulse rate during the shift is 61 beats per minute

which is in the normal range. The pulse was strong with

regular rhythm. With regards to emotional stress and

physical activity, the pulse rate increases. The patient’s

blood pressure is 140/100. This was taken while the patient

is lying down in the bed.

X. Respiratory status

Her respiratory rate is 22 breaths per minute with use of

accessory muscles. On O2 inhalataion regulated at 2-3

liters per minute. There are crackles heard on both lung

fields upon auscultation. The patient’s lip’s color is

pinkish but slightly dry along with her nails. Her o2

saturation during the shift ranges from 90-92 %.

XI, Temperature Status

Patient’s axillary temperatures is 36.5 C. There is no

sign of profuse sweating or even i r r i t a t e d . T h e

environmental temperature is cold and the

h u m i d i t y i s h i g h a n d t h e p a t i e n t i s comfortable with

it.

XII. Integumentary Status

Skin color is brownish and has a skin turgor at >3 seconds.

There are no wounds noted or reported by the patient. Nails

are trimmed, hair is white in color. There are no odorous

secretions or oily secretions.

XIII. Comfort and Rest Status

The patient claims that normally she sleeps 6-8 hours in a

day. Her sleep was now only 4-6 hours during

hospitalization. She claims that she is very comfortable

with her sleep even if she is in the ward but sometimes

being disturbed when nurses have to get her vital signs or

give medications