I.

Patient’s Profile
1. Personal Data
- Mrs. X is a 59-year-old black female who is a housewife.
2. Admitting Diagnosis
- She was brought in to the hospital complaining of Chest Pain.
3. Final Diagnosis
- Jugular Vein Distention

II. 13 Areas of Assessment

1. Psychosocial and Psychological Status
- Mrs. X is a 59 year-old black female. She is a housewife with 3 children. She is very dependent
in terms of her health to health care professionals. The patient and her family is Roman Catholic
and have no practices or beliefs which might affect to providing health care. Watching the
television is her way in spending her leisure time and she has positive outlook with her life.

Erick Erickson’s Psychosocial Theory

- Based on Erickson’s psychosocial theory, Mrs. X on her adulthood is classified

under Generativity vs. Stagnation which explains that the most important events are
productivity and caring about others. She is establishing and guiding next generation by "giving
back" to society with creativity, productivity and concern. In Mrs. X’s case, she values her
relationship with her wife and children. She guides them in everything they do and they try to
solve things together and support each other.

2. Mental and Emotional Status

- The patient is conscious but anxious about her condition. She is responsive in verbal stimuli,
noise, light, touch and pain stimuli. She is oriented to current time, date and place. She
manifests grimaces upon initial assessment and she verbalized that she is afraid to die.
However, she still acts according to her age and cooperate to prevents some things to further
cause damage to her health.

3. Environmental Status
- There are no sensory deficits and she is oriented that she is in the hospital. Patient is afraid
about her conditions but there is steady pattern of activity, light noise and color in her
environment which quite distract her. The food and water or side table is placed at the right side
of the patient and is accessible for her needs. Patient is in the Medical Ward together with her
children.

4. Sensor Status
a. Visual Status
- In assessing the vision, patient is instructed to look straight to observe the general appearance
of her eyes. Eyes are almond in shape, irises are black in color, scleras are whitish in color,
and eyebrows and eyelashes are equally distributed. Patient is also instructed to follow the
direction of a finger with her eyes following six cardinal gazes, and her eyes were able to
move in full range of motion and in all directions. There is no known visual deficit like color
blindness. The patient does not use eyeglasses or contact lenses.

b. Auditory
- General appearance of Mrs. SK’s ears were parallel, symmetrically proportional to the size of
the head and bean shaped, firm cartilage and with a presence of cerumen. She can also
distinguish voice even from a distance, loud or soft. No corrective auditory deficits nor
infection history and unusual sensations like ringing or buzzing. There is also no auditory
device noted being used by the patient.

c. Olfactory Status
- Patient’s nose has no deviation in terms of shape and size. No discharges were seen during
 assessment, according to the patient, she doesn’t
have any history of sinus infection. She can also identify scented object even with close eyes.
There are no abnormalities or obstructions were identified in the sense of smell.

d. Gustatory Status
- Mrs. X’s lips were symmetrical in shape but bluish in color during the initial assessment. There
is presence of tooth decay. No dentures and no signs of gingivitis. Patient was able also to
identify correctly the taste of the food that is being served to her.

e. Tactile Status
- She was able to distinguish sharp and dull, light and firm touch. She is also able to perceive
heat, cold, pain in proportion to stimulus. She was asked to close her eyes, a cotton ball was
stroke to the back of her neck, then using another cotton ball, alcohol was poured on it and
rubbed it on the same area, and she stated that she felt a sensation of wet and cold on her skin.
Using the case of BP apparatus which is rough in texture and the medical kit which is smooth in
texture, the patient is asked to touch the two materials and ask the texture while blindfolded.
After the test, she correctly identified the difference of two materials.

5. Motor Status
- Motor strength is assessed. Her movements are limited since she is experiencing chest pain and
shortness of breath and is under O2 therapy 2lpm via NP. No prosthetic device was noted
present with the patient and all her extremities are intact. She verbalized that her children assist
her whenever she needs something.

6. Thermoregulatory Status
- Mrs. X is febrile. There is a sign of profuse sweating. However, the room is ventilated which
helps with the condition of the patient.

Date Time Temperature

January 21, 2021 7am 37.6 °C

January 22, 2021 7am 37.4 °C

January 23, 2021 7am 37.2 °C

7. Respiratory Status
- Her rhythm and respiration pattern are irregular. She is experiencing chest pain and has an
ineffective breathing pattern which doesn’t provide adequate gas exchange. Lungs were
auscultated for adventitious sounds and noted crackles on both bases of her lungs. She uses
her accessory muscles during respiration and noted nasal flaring. She is under O2 therapy at 2
lpm via nasal prong.

Date Time RR SPO2

January 21, 2021 7am 26 bpm 86 % on room air

January 22, 2021 7am 24 bpm 90% ↓2L O2

January 23, 2021 7am 22 bpm 90% ↓2L O2

8. Circulatory Status
- The pulse rate during the initial assessment is around 128 bpm which is quite high. Cardiac
auscultation reveals a rapid regular rhythm and a murmur. Her blood pressure is also high
which is because of her HPN and the chest pain that she is experiencing in relation to jugular
 vein distention. However, with immediate treatment, her BP went down together with her
pulse rate at the end of the shift.

Date Time BP CR

January 21, 2021 7am 200/110 mmHg 128 cpm

January 22, 2021 7am 190/100 mmHg 116 cpm

January 23, 2021 7am 180/95 mmHg 108 cpm

9. Nutritional Status
- The patient food is being served in the hospital three times a day. The food served is usually
appropriate and is according to her diet which is low Na and low fat diet because patient has
HPN. 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 or
vomiting and she is eating orally by herself.

10. Elimination Status

- The patient has no difficulty in elimination. During the assessment, she verbalized that she
defecated once daily. The stool is usually brownish and semi-solid. She also frequently urinates
during her stay at the hospital. She urinated 2-3 times during a shift and is usually dark-
yellowish. The patient claimed absence of special problem like urinary and bowel retention,
urinary incontinence and diarrhea. She usually consumes 1-2 liters of water per day and denies
feeling of thirst.

11. Sleep, Rest and Comfort Status

- The patient claims that normally she sleeps around 6 hours in a day. Her sleep was now only 5
hours during hospitalization. She claims that she is uncomfortable with her sleep in the ward
and sometimes being disturbed when nurses have to get her vital signs or give medications. She
also complaints of her chest pain which she rated 8/10 on the pain scale of 1 being the lowest or
no pain at all and 10 being the highest with worst pain possible. She was given nitroglycerin for
chest pain and she is complying very well with the medication.

12. Fluids and Electrolytes Status

- The patient usually drinks 1-1.5 liters of water daily and urinates regularly. The patient denies
the feeling of thirst and her capillary refill is 2 seconds.

13. Integumentary Status

- Skin color is pale due to her jugular vein distention. However, there are no wounds/skin lesions
noted or reported by the patient. Nails and hair are well kept by the patient and has no history of
skin allergy.