Adepoju Iyinoluwa

13 AREAS OF ASSESSMENT

1. Patient’s Profile.
Ms. B is a 44 years old, female, married, a dressmaker and a Roman Catholic, she was
admitted to the Emergency ward due to vaginal bleeding with a new diagnosis Hydatidiform
Mole, and Severe Anemia, she has no history of chronic illness.
2. Psychological
Information about pt. family and social life wasn’t given. Pt. has no physical disability, and
pt. appears weak.
3. Mental and Emotional Status
The patient is conscious, she responded to procedures as it was stated that she signed
consent for admission and management in verbal stimuli, which shows she’s is very
cooperative, appeared in weak and pale.

4. Environmental Status
Ms. B is partially aware of her environment, conversant, oriented to self and others around.
She is aware of the time, date, and place where she was confined.
5. Sensory Status
Ms. B is approximately 5’1 in height. She has proportionate body built with symmetrical
facial contour, no eye defect stated and clearly hears and understand words spoken.
6. Motor Status.
Pt. has limited ROM appears weak but was able to walk in the hospital.
7. Nutritional Status
Not given.

8. Elimination
Urine color is dark yellow and has some abnormal findings after urinalysis test was taken.
9. Fluids and Electrolytes.
Pt. has an IVF of PLR 1L + 10 “U” oxytocin at the level of approximately 900 ml.
10. Circulatory Status.
Patient has a pulse rate of 85bpm and capillary refill data wasn’t given but blood pressure of
120/70 mmHg was taken
11. Respiratory Status.
RR taken was 21cpm and no records of DOB.
12. Temperature.
36.5 0c which is normal.
13. Integumentary.
Data wasn’t given but due to inserted IV lock skin integrity might occur
14. Comfort and Rest.
No provided information but pt will obviously have difficulty in sleeping due to pain and
discomfort.