Don Mariano Marcos Memorial State University

South La Union Campus

INS TITUTE OF C OMMUNITY HEALTH AND ALLIED MEDIC AL SC IENC ES
Agoo, La Union
Tel. 072.682.0663/ichams.dmmmsu-sluc.com
Embracing World Class Standards Care to learn, Learn to care

13 AREAS OF ASSESSMENT
-------------------------------------

1. Psychosocial Status. This area deals with the person’s roles in relationship to
others-family, workgroup, and health professionals. If the nurse were attempting to
diagnose the problems of a group of persons, this area would include the social
relationships within those group-patterns of leadership, methods of resolving conflict.
However, beginning practice generally deals primarily with individuals, and the outline
of data needed will focus only on that needed for an individual

A. General Social Status

1.Ethnic background
2.Occupation-status or position in that occupation
3.Economic status
4.Religious practices
a. Religion, Affiliation
b. Practices or beliefs which might affect reaction to health care(proscriptions
against transfusion, immunization or blood beliefs about the cause of disease
5.Type of housing accommodation
6.Contact or previous referrals to social agencies
B.Family or Peer Group Social Status
1.Position in the family (father, mother, etc.)
2.Others in family
3.With whom the person lives; that he or she considers close if he or she lives
alone
4.Marital status
5.Role in family (e.g. source of support during crisis,” black sheep”,etc.)
C.Social developmental Status
1.Age
2.Sex
3.Marital Status
4.Degree of dependence and independence (prior to and during health deviation)
5.Sexuality
a. Level of sexual development
b. Attitudes toward own sexuality
c. Reproductive data (male and female)
i. Number of children, number of pregnancies, number of live births (self,
spouse, or significant sexual partner)
ii. Attitude toward contraception; contraceptive methods if used
iii. Difficulties related to menopause
d. Reproductive organs
i. Appearance of genitalia; presence or absence of lesons; abnormal
innervations
ii. Unusual genital discharge
iii. Menstrual pattern, age of menarche
iv. History of disease or surgery affecting reproductive organs
 Don Mariano Marcos Memorial State University
South La Union Campus
INS TITUTE OF C OMMUNITY HEALTH AND ALLIED MEDIC AL SC IENC ES
Agoo, La Union
Tel. 072.682.0663/ichams.dmmmsu-sluc.com
Embracing World Class Standards Care to learn, Learn to care

2.Mental and Emotional Status. These are considered as one category since one’s
intellectual growth bears on reaction to self and others, and vice versa. There s
overlap between the psychosocial area and the mental emotional area, but the
student need not waste energy trying to fit a piece of data precisely into one category.
The important thing is to note the information somewhere.
A. Mental Status
1.Level of consciousness (response to verbal stimuli, response to noise and light,
response to touch and painful stimuli, spontaneous activity)
2.Orientation to time, place, and person.
3.Intellectual development relative to age
4.Mental skills (level of education, ability to read and write, vocabulary, ability to
comprehend and follow directions, attention span, memory span, ability to
understand abstraction)
5.Perception and understanding of health problems and goals of medical and
nursing therapy
6.Beliefs and attitude about disease
7.Previous experiences with and reaction to illness and hospitalization
B.Emotional Status
1.Affect (general mood and emotional response)
2.Reactions to stressful situations (includes kinds of situation person considers
stressful)
3.Patterns of relating to others
4.Special concerns or fears.
5.Concepts of self---self esteem (prior to and in relation to current health problems;
body image)
6.Substance taken to alter emotional response (includes prescribed medications---
tranquilzers, sedatives, mood-elevating drugs; alcohol; mind expanding drugs;
amphetamines)

3. Environmental Status. Factors in the clients’ home, work, or institutional

environment are assessed in several other areas. However, some factors, related to
safety, control of infection,
And environmental effects upon illness need to be assessed in their own right.
A. Safety Factors
1. Age
2. State of mobility
3. Arrangements of objects in physical environment; other potential safety hazards,
4. Sensory deficits
5. OrIentation, disorientation to environment
6. Use of restraining device.
7. Use of prosthetic and other supportive devices---crutches, artificial limbs,
mechanical lifting device
B.Infection Control
1. Prescence of infectious disease or infected wounds in patients, family, or others
in proximity
2. Barriers to cross infection (isolation techniques, hand-washing facilities, distance
from infected persons or infectible persons)
3. Patient and family understanding and beliefs about transfer of pathogens
4. Equipment potentially harboring Pathogens (Isolates, humidifier, pulmonary
therapy equipment)
C. Environmental Effects on Illness
1. Patterns of activity, light, noise, color (varied, steady, excessive, absent)
2. Arrangement of environment in relation to functional abilities or disabilities (are
pictures and reading materials place where bedfast person can see them? are
equipments placed where handicapped person can reached them?)

4. Sensory Status. This area refers to the state of perceiving senses---vision,

hearing, smell, and taste, touch. Language perception and formation are categorized
here although they are dependent upon both sensory and motor function.
A. Visual Status
1. Visual Acuity (ability to distinguish objects at a specified distance), papillary
response
2. Field of vision (lateral, horizontal, vertical, extraocular movements)
3. Known deficit (myopia, presbyopia, blindness, astigmatism, etc.)
4. Corrective or prosthetic device (glasses, contact lenses, artificial eye)
5. Unusual sensation (rainbows around light, blind spots, flashing lights)
B. Auditory status
1. Ability to distinguish voice (distance, loudness)
2. Known deficit
3. Corrective device
4. Unusual sensation (ringing, buzzing, dizziness)
C. Olfactory Status
1. Ability to discriminate odors
2. Unusual sensation (lack of smell, heightened sensitivity to smell, smelling odors
with no stimulus present)
D. Gustatory Status
1. Ability to discriminate sweet, sour, salty, and bitter
2. Unusual sensation (lack of taste, substance taste alike
E. Tactile Status
1. Ability to discriminate sharp and dull, light and firm touch
2. Ability to perceive heat, cold, and pain in proportion to stimulus
3. Ability to differentiate common objects by touch (stereognosis)
4. Intactness of body image
5. Abnormal sensation (lack of pain, touch, heat, cold sensation, increased or
decreased pain in proportion to stimulus; diffuse burning, pricking or pain)
G. Sensory Environment
1 .Intensity
2. Pattern
3. Variety
4. Appropriateness to developmental level

5. Motor Status. This area evaluate the ability of the person’s nervous system to
initiate action
A. Medical restrictions on activity (Physician’s prescription for bed rest,CBR with out
BRP’s, etc.)
B. Musculoskeletal status
1. General movement (coordination, ease, stability)
2. Muscle strength, tone, and mass (all extremities, trunk and abdomen; symmetry;
prior to and during health problem)
3. Range of joint motion (all joints, active and passive motion)
4. Posture
5. Handedness
6. Deformities

7. Abnormal innervations to muscles (paralysis, weakness)

C. Mobility
1. Method of ambulation (assisted, with supportive aids such as cane, crutch and
wheelchair)
 2. Gait (mode of walking, coordination, stability)
3. Endurance (amount of activity tolerated)

6. Nutritional Status. This area deals not only with obvious data about intake of
foods but also with attitudes toward eating and toward special diets
A. Dietary Habits
1. Usual eating habits (number and time of meals, inclusion of “basic four”
categories of food, preferred foods excesses)
2. Appetite
3. Changes related to health problem (appetite changes, special diet prescribed by
physician or by patient-client)
4. Person responsible for preparing food at home
B. Adequacy of Diet
1. Height, weight; gain loss pattern
2. General appearance
C. Attitude toward eating
1. Importance of food to feeling of well being
2. Religious dietary restrictions
3. Symbolic meaning of food (reward, love, punishment)
D. Factors in Food Ingestion
1. State of teeth (dentures, partially or completely edentulous; disease of teeth and
gums; oral hygiene habits)
2. State of mouth (intactness of mucous membranes; disorders of salivary glands;
moistness; presence of debris)
3. State of consciousness
4. Ability to swallow
5. Gastrointestinal motility, bowel sounds
E. Digestion
1. Ease of digestion
2. Nausea, vomiting
3. Eructation (belching)
4. Medications affecting digestion and metabolism of foods
F. Non-oral Means of Feeding
1. Parenteral fluids; hyperalimentation
2. Nasogastric tube, gastrostomy
7. Elimination Status. This category includes elimination via the urinary and
gastrointestinal tracts.
A. Normal Patterns (frequency, amount, color, consistency of stool)
B. Aids to Elimination Normally Used (beverages, laxatives, position)
C. Changes Due top Health Problems
1. Character of urine (color, odor, specific gravity, unusual constituents)
2. Character of stool (color, odor, consistency, presence of unusual
constituents)
D. Method of Eliminating (toilet, commode, bedpan)
1. Artificial orifices (ileal conduit urine; colostomy, ileostomy – bowel)
2. Method of care of excretions from artificial orifices

E. Special Problems
1. Incontinence (urine, stool; ways of coping)
2. Urinary retention
3. Constipation
4. Diarrhea
5. Abnormal bowel sounds
8. Fluid and Electrolyte Status. Maintenance of balance of body fluids and
electrolytes is essential to homeostasis and to life. Although the physician has primary
responsibility in restoring this balance nurses observations often provide key data for
the medical management. In addition, the nurse may play an important role in helping
to maintain this balance.
A. Normal Patterns of Fluid Intake and Output
1. Ingestion of food and fluids (amounts in 24 hours, types preferred)
2. Output (urine, stool, perspiration)
B. Changes Due to Health Problem (increase or in intake and
C. Measurements
1. Oral and parenteral intake (includes type of solid foods)
2. Output (urine, liquid stool, number of formed stools, drainage from
wounds, occasionally perspiration and respiratory loss)
D. Indirect Data
1. State of Fluid Balance
a. Weight
b. Thirst
c. Skin turgor, dryness
d. Condition of mouth, mucous membranes (dry, moist, coated,
presence of crust)
e. Edema
f. Blood pressure, lying and standing
2. Venous state (distended, flattened, filling time)
3. Level of consciousness
4. Depression or elevation of fontanels in infants
5. Neuromascular flaccidity or irritability
6. Laboratory values of electrolytes, pH
7. Medical therapy (drugs, parenteral fluids, blood)
9. Circulatory Status. These observations give indirect data about the state of
the heart and blood vessels.
A. Pulse
1. Rate
2. Quality (thready, weak, bounding, strong)
3. Rhythm (regular, irregular, paired beats)
4. Apical-radial differences
5. response to activity, emotional stress
6. medications which alter heart rate or rhythm
B. Heart Sounds
C. Blood pressure
1. systolic, diastolic
2. lying and standing
3. discrepancies between arm
4. factors altering accuracy of reading ( obesity, cuff size)
 D. General appearance
1. Color (skin, lips, nails)
2. evidence of volume depletion or edema
3. urine output, fluid intake
4. warmth and color of extremities
5. undue fatigue alter exertion
6. pains in legs after walking
7. chest or epigastric pain, precipitating factors
E. Special Observations. If the patient has acute cardiac disease and his or her
condition is being specially monitored, the list may also include data from
monitoring devices such as the character of the electrocardiogram, central
venous pressure, arterial pressure..

10. Respiratory Status. The state of the respiratory function may be assessed both
directly and indirectly. The indirect measurements give some clues to the state of
cellular respiration
A. direct measurements
1. patency of the airway
2. respirations
a. rate, rhythm, depth, ease, use of accessory muscles
b. Factors altering character (position, emotion, cough, humidity, air
pollution)
c. Breath sounds
3. Cough
a. patterns (upon arising, continuous, random, after smoking)
b. Productive of sputum
c. Character of sputum (color, viscosity, odor, hemoptysis)
B. Indirect Measurements
1. Smoking History
2. Medications affecting respiratory rate, patency of bronchial tree
3. Color (skin, lips, nails)
4. Clubbing of Nails
5. Posture, skeletal defects such as kyphosis
6. Level of consciousness (increase or decrease)
7. Anxiety or Apprehension (diffuse or specific regarding breathing)
8. Laboratory values (PaO2, PaCO2, pH)
C. Supportive Devices
1. Nebulizers, aerosols (patterns of use, effectiveness)
2. Positive pressure breathing
3. Tracheostomy

4. Assisted or controlled ventilation with respirator

11. Temperature Status

A. Subjective feeling of warmth and cold
B. Usual measures of temperature comfort
C. Body Temperature
1. oral
2. rectal
3. axillary
D. Perspiration
1. Presence or absence

2. Pattern (night, day, intermittent)

 E. Environmental Temperature and humidity
F. Methods of altering temperature
1. convection, conduction, radiation, evaporation
2. special equipment (hypo-hyperthermia blanket)

12. Integumentary Status. This area refers to the condition of the skin and underlying
tissues, mails and hair.
A. Skin Condition
1. Color, turgor
2. Intactness (presence of wounds, incisions, ulcers, pressure sores, diaper
rash)
3. Character of any lesions present (dry, draining, infected)
4. Areas of ischemia
5. Factors predisposing to skin breakdown (prolonged pressure, lack of position
change , unprotected bony prominences, incontinence, age, hyperactivity,
self-destructive tendencies)
B. Condition of Nails and Hair
C. Habits of Personal Hygiene
D. Odos and Excretions (oily, perspiration, abnormal)

13. Comfort and Rest Status

A. Sleep
1. Normal sleep pattern (number of hours, time, feeling of being rested)
2. Alterations due to health problem
3. Aids used for sleep (beverages, warm bath, medications)
B. Comfort
1. Presence of pain or discomfort (location, duration, degree, extent,
character, precipitating factors)
2. Use of aids to relieve pain or discomfort (prior to and during current health
problem)
3. Changes in pain or discomfort with current health problem