13 Areas of Assessment

I. SOCIAL STATUS

Years prior to admission, patient was a loved and well-respected teacher. But before she
became a teacher, she failed her boards three times. Patient experienced depression after being
failed 2 times. According to her sister, she was very jolly and active sister before she failed her
boards, and after 2 consecutive fail, she began to show changes on her attitude. She became more
conscious on what she was doing. She makes sure that everything is organized and must be come
out as planned. When she was 45 years old, she retired and stayed at home by herself most of the
time. According to her sister, the patient and her are the only ones in the house. They have a
good relationship to one another though she knows about the patient’s mental condition.
NORMS
Social status includes family relationship that states patient’s support system in time of
stress and in time of need. It meets a fundamental human need for socialities making life less
stressful and social support buffers the negative effects of stress. Thus indicating indirectly
contributing to good health outcomes. (Fundamentals of Nursing, Barbara Kozier, Seventh
edition)
Analysis/Interpretation:
Depression is not a normal state of mind of a well person. It can cause to multiple
alteration in our brain. But good thing patient got her sister to support her and help her, even
until now that the patient.
II. MENTAL STATUS

Patient responded to us in a normal manner, meaning we asked her and she answered properly
and has sense. She was a teacher graduate, confirmed by her caregiver. She is fluent in speaking
English, and even her main dialect which is tagalog. She was also voluntarily sharing things
about herself and how she got her disease. But according to her caregiver, she has mental
problems. Not officially diagnosed, but they are observing signs like talking to herself, shouting
out of nowhere, and instant changes in her behavior.
NORMS:
The content of the patient message should make sense. The ability to read and write should
match the educational level. The patient should be able to correctly respond to the questions and
to identify all objects as requested. The patient should be able to evaluate and act appropriately
in situations requiring judgement. (health assessment and physical examination 3th edition by
Mary Ellen Zator Estes)
ANALYSIS:
The way the patient responds to us was clear, but
III. Emotional Status
 She appears calm and accommodating to answer our questions that are being asked. She said
that she is happy because she can able to survive the operation. And her husband is there to
be with her through the situation.

Norms:
A human’s emotional status depends on his or her ability to cope up and be ready
for whatever can happen in their life. She or he may not be ready to be emotionally
stable of unfortunate happenings in life. (www.nursingceu.com)
Analysis:
Emotional status is normal.

IV. Sensory Perception

Sense of sight

The eyes of the patient are equally round and her pupils are dark brown. Her eyebrows are
symmetric and with equally distributed hair. Patient’s eyes are equally reacting to light when
using penlight. She is wearing reading glasses when she needs to read small words but still her
vision is 20/20 because she can able to read the words being asked 20 feet away. No
exopthalmia, lesions, and bruits observed.

Norms:
The normal vision of an average person is 20/20 in distance of 20 feet away and doesn’t
wear any corrective graded lenses. The eyes must be symmetrical during the six cardinal gaze
test and symmetrical in movement. (Health assessment and physical examination, Mary
Ellen Zator Estes)
Analysis: Based on the norms she has normal vision.
Sense of smell
Her nose is in the midline of the face and is symmetrical. With no secretions
noted. Common foods such coffee were provided and also alcohol in a cotton ball.
She was able to identify odor.

Norms:
The person can smell and identify the aroma of a given object like perfume or any
other. The person should be able to distinguish the foul and good smelling.
Analysis:
She has normal sense of smell.
 Sense of hearing
For the auditory assessment the voice whisper test was used. Words were whispered
while the patient was instructed to repeat every words being whispered. The procedure
was then repeated to the other ear. The ear are symmetrical and matches the color of the
rest of the skin. After whisper test patient was able to hear them clearly with negative
deformities. No swelling, discharged and lesions noted except for minimal earwax
observed on both ears.
Norms:
The auditory of the person is normal if the patient don’t have any tinnitinus or any
ear problem. He should be able to hear in the minimum of 2 feet away. ( health
Assessment and physical examination, Mary Ellen Zator Estes)

Analysis:
Based on the given data, auditory acuity is normal.

Sense of taste
Examined using variety of food which taste salty, bitter, and sweet (granules of
sugar and coffee). She was able to differentiate each taste. She has pale lips slightly dry
and chaps. With dry saliva deposited on her side mouth, her tongue is slightly pinkish
with whitish buds. Foul odor is being noted with no deformities that can affect her sense
of taste.
Norms:
A person usually identifies the taste of bitter, sweet and sour. By the use of our sense
of taste we can fix or adjust the taste of our cooked food based on our taste capacity. ( health
assessment and physical examination, Mary Ellen Zator Estes)
Analysis:
Based on the assessment the sense of taste is normal.

Sense of touch (tactile sensitivity)

The examination of sensation she was instructed to close her eyes and tell what she
feels when she was being pricked on her palm. She responded and stated that the
pricking is painful. Using a small glass with cold water pat on her skin for few
second, and was able to identify that is cold.
Norms:
The tactile sensitivity or hypersensitivity is an unusual or increased sensitivity to
touch that makes the person feel peculiar, noxious, or even in pain. It is also
called tactile defensiveness or tactile oversensitivity. Like other sensory
processing issues, tactile sensitivity can run from mild to severe.
Analysis:
 The sense of touch or the tactile sensitivity is normal.

V. Motor Stability
Her neck is symmetrical with head in central position. Movement through full range
of motion can be done with discomfort, and gait was assessed using the heel to toe
method. She can’t able operative inscision. She can also move her shoulder laterally
and medially as well as rotate her shoulder in the same manner with complains of
pain. She can also bend her elbows and extend beyond the neutral position. The
patient can’t flex her knees because she’s still in pain.

Norms: Normal motor stability includes the ability perform different activities. It
should be firm and coordinated movements. (Estes, 2006)
Analysis:
The motor stability is noted abnormal due to impairment with some physical mobility
due to pain cause by post operative incision.
VI. Body Temperature

February 05, 2019 (1:00 36.8 C normal

pm)
N
February 06, 2019 (8::01 36.4 C normal
o
am)
r
February 06, 2019 (4:29 36. 7 C normal
m
pm)
s
: Normal body temperature is within 36.4 C to 37.4 C. (Health assessment and
physical examination 3rd edition by Mary Ellen Zator Estes)

Analysis:
Upon assessing body temperature during assessment and follow-up are normal.

VII. Respiratory Status

 February 05, 2019 (1:00 23 Above normal
pm)
February 06, 2019 (8::01 20 normal
am)
N
February
o 06, 2019 (4:29 24 Above normal
pm)
r
ms:
Normal respiratory rate for adult is 12-20 cpm, average is 18. In terms of pattern,
normal respirations must be regular and even in rhythm. The normal depth of
respirations in non-exaggerated and effortless (Health assessment and physical
examination 3rd edition by Mary Ellen Zator Estes)

Analysis:
Respiratory status are beyond normal because pain and post anesthetic during follow-
up.

VIII. Circulatory Status

February 05, 2019 (1:00 80 bpm normal

February 05, 2019 (1:00 120/80 normal
pm)
pm)
February 06, 2019 (8::01 78 bpm normal
February 06, 2019 (8::01 110/70 normal
am)
am)
February 06, 2019 (4:29 105 bpm Above normal
February 06, 2019 (4:29 130/70 Above normal
Norms: pm)
pm)
N
ormal cardiac rate for an adult is 60-100 beats per minute while the normal blood
pressure is 120/80 mmHg. The working capacity of the heart diminishes with aging.
The heart rate of older people is slow to respond to stress and slow to return to normal
after stress. Reduced arterial elasticity results in diminished blood supply to the parts
of the body especially the extremities. (Health assessment and physical examination
3rd edition by Mary Ellen Zator Estes)

Analysis:
The pulse rate during the assessment and follow-up are in normal range. the blood
pressure on the follow- up are above normal.

IX. Nutritional Status

Prior to hospitalization she verbalized that she takes her meal 3x a day consist of
combination of meat, vegetables, fish and fruits. And consume 8-10 glasses of water
 she’s fond of eating fatty and salty foods. Her BMI is 31.95 and considered obese.
Prior to pre operative she was ordered to carry NPO diet. During post operative she
carried NPO until normal peristalsis occurs followed by soft diet and small amount of
intake as ordered by the doctor less salt and fat.
Norms:
Consider cultural and religious variations. Normal eating pattern is at on the
minimum of three times per day depending upon the metabolic demands and needs of
the patient. Fluid intake is on the average of 8-10 glasses per day (Monahan, 2002).
Analysis:
The nutritional status was being altered for operation preparation (NPO).She has
above normal BMI.
X. Elimination Status
Prior to hospitalization she defecates at least once a day brown stool moderately soft
and urinates five times in a day. During 1st day before operation she defecates once but
after the operation she didn’t defecate and still waiting to her normal peristalsis.
Norms:
An individual usually defecate one to two times a day or every 2 day and urinates
30cc/hr. (Nutrition by Alex Abelos)
Analysis:
elimination status is normal.

XI. Reproductive Status

She had her first menstruation when she was 11 years old with 5 days duration and consumes 5
pads in a day fully soaked, with severe abdominal cramps and fundal pain every menstruation.
No intercourse was claim by the patient. She was diagnosed of having myoma when she was 41;
operation was done electively, and got menopause since.
Norms:

The first menstruation which is menarche occurs at an average of 9 to 17 years old. (Maternal
and Child Health Nursing 4th edition by Pilliterri)
Analysis:

Her menarche is normal because she had her menarche at 15 years old. The reproductive status is
not normal due to the alteration of the reproductive system as evidenced by
XII. Sleep-rest Pattern

Prior to her admission, she was sleeping by 10 in the evening and waking up at 5 in the morning.
She doesn’t have any difficulty in sleeping. Even when she got confined, she still sleep in her
normal routine time.
Norms:
Sleep refers to altered consciousness with general slowing of physiologic process while rest
refers to relaxation and calmness, both mental and physical. A person usually sleeps for about 7
to 9 hours a day and takes a rest using some of activities that will help you to relax including
reading, watching television and others
Analysis:
Sleep-rest pattern is normal because there is no alteration even when she got confined.

XIII. State of skin appendages

She has ash-gray appearance. Alopecia is present on some parts of her hair due to her
mannerism. Eye bags are emphasized. Presence of bruises all over her body. Bulge vein and
edema was present in her left hand. Long and pail nails and dirt in her nails both finger and toes
are assessed.
Norms:
Obvious changes in the integumentary system (skin, hair, nails) with age. The skin becomes drier
and more fragile, the hair loses color, the finger nails and toe nails become thickened and brittle,
and i women over 60, facial hair increases. These integumentary system changes accompany
progressive losses of subcutaneous fat and muscle tissues, muscle atrophy, and loss of elastic
fibers. (Fundamental of nursing 7th edition by Barbara kozier)
Analysis:
Some of the assessed signs are normal to patient who is undergoing dialysis like the edema and
bruises on her body, but her long nails and dirt in her nails indicated poor hygiene.