IX.

Nutritional Status

Upon interview, Patient X states that he eats his meals thrice a day; one for breakfast, lunch,

and dinner. He also said that the vegetables he eats are from their garden that are mainly composed

of eggplants, okra, and sweet potato leaves. Red meat and fish were also in his diet which they

acquire from their local talipapa and claims to eat a lot of rice per meal, ranging from 3-4 cups

daily depending on the dish served. We also asked for his water intake and says that he drinks 5-6

glasses of water daily and drinks alcohol occasionally with his good friends, having 3 bottles of

liquor per session paired with 3-5 sticks of cigarettes per day that he consumes.

Nutritional Parameters

Parameter Norms Analysis

Height: <16=Malnourished

179 cm 16-19=Underweight Moderate to severe

Weight: 20-25=Normal obesity

85 kg 26-39=Moderate to severe obesity

BMI: 40 and above=Morbidly obese (Fundamentals of Nursing by

26.5 kg/m2 Kozeir, et al.)

Norms:

According to the Health Asian Diet Pyramid, there should be a daily intake of rice, grains,

bread, fruit, and vegetables; optional daily for fish, shellfish, and dairy products; weekly for

sweets, eggs and poultry, and monthly for meat. There should be an increase intake of a wide
variety of fruits and vegetables. Include in the diet foods higher in vitamins C and E, and omega-

3 fatty acid rich foods. (www.webmd.com) Fluid intake is on the average of 8-10 glasses per day

(Mohan, 2002). BMI is a measurement that indicates body composition. The degree of overweight

or obesity as well as the degree of underweight can be determined using BMI. The normal BMI

ranges from 18 to 22. (Mary Ellen Zator Estes, Health Assessment, 2006)

Analysis:

Patient X’s eating behavior is normal in terms of eating thrice a day with meals composed

of vegetables, meat, and fish paired with 3-4 cups of rice along with an intake of 5-6 glasses of

water daily that he lacks when it should be 8-10 glasses per day as recommended. This suggests

that his diet is composed of a more than normal amount of carbohydrates that contributes to his

obesity (BMI of 26.5 kg/m2) along with his alcohol intake which is indicative of a bad diet.

X. Elimination Status

DAY 1: DATE ADMITTED

VOIDING
DATE ASSESSED TIME VOLUME
July 05, 2021 7:00 AM 18 ml
July 05, 2021 1: 00 PM 108 ml
July 05, 2021 7:00 PM 216 ml

DAY 2

VOIDING
DATE ASSESSED TIME VOLUME
July 06, 2021 7:00 AM 19 ml
July 06, 2021 1: 00 PM 114 ml
July 06, 2021 7:00 PM 228 ml
 DAY 3

VOIDING
DATE ASSESSED TIME VOLUME
July 07, 2021 7:00 AM 22 ml
July 07, 2021 1: 00 PM 132 ml
July 07, 2021 7:00 PM 264

DAY 4

VOIDING
DATE ASSESSED TIME VOLUME
July 08, 2021 7:00 AM 28 ml
July 08, 2021 1: 00 PM 168 ml
July 08, 2021 7:00 PM 336 ml

Upon the assessment, patient was seen with an indwelling foley catheter that was ordered

for him due to his difficulty in urinating and oliguria that were present as part of the clinical

manifestations of the disease. The color of his urine was also a little bit dark in color. When asked

if he also has difficulty in passing his stools, he says that he feels a little bit pain that’s why he

only defecates once in two days with a characteristic of his stools that are soft in consistency or

watery that is brown in color, depending on what type of food he had eaten.

Norms:

Normal bowel movement of a person must be 1 to 2 times a day and voiding in 3 to 4 times

a day with an output of 1200 to 1500 ml a day. A normal stool is brown in color and well formed,

urine is clear to yellowish in color. (Fundamentals of Nursing, kozier, 2007)

Analysis:

Patient’s elimination status is not normal due to the dysuria and oliguria that was seen on

that patient’s chart along with difficulty of passing his bowels that he is experiencing due to his

illness. It was also seen that his urinary status gradually becomes better overtime as a result of his

treatment in the hospital, showing on the fourth day that he is no longer experiencing oliguria.

XI. Reproductive Status

Patient X reported that he had noticed changes in his voice at the age of 13 in which his

height also increased at the same age. His facial hairs also began to grow at around 16 years old.

His last intercourse with his wife was around five months ago, when he didn’t start to feel the

symptoms of the disease manifest on his body.

On the day of the assessment, his genital hair is well distrbuted. Penis’ surface

characteristics, color, lesions and discharge is also clear. Scrotum, sacrococcygeal areas, perineal

area and inguinal region and femoral areas also clear and shows no masses or bulges being found.

Norms:

Examination of the penis includes the skin, corporal erectile bodies, and urethral meatus.

It should be noted whether the patient is circumcised or uncircumcised. The ease with which a

redundant prepuce is retracted is assessed. The entire penile skin, including that beneath the

prepuce, should be examined for ulcers, warts, rashes, or other lesions. The size and position of

any skin lesion should be described along with the degree of tenderness to palpation and fixation

to subcutaneous tissue. If penile skin lesions are found, correlation of palpable deep or superficial

inguinal adenopathy should be made at that time. Examination for urethral discharge or urethral
mucosal lesions near the meatus should also be carried out by everting the lips of the meatus.

(Maxwell White, Clinical Methods: The history, Physical, and Laboratory Examination. 3rd

edition.)

Analysis:

There were no alterations observed in the patient's reproductive organ upon doing the

assessment. On the scrotum, the anterior and posterior scrotal skin appears darker in pigmentation

with rugous or wrinkled surface. Cacrococcygeal areas skin is clear and smooth with no palpable

mass being detected. Perineal area skin surrounding the anus is coarse with darker pigmentation.

Anal sphincter is closed.

XII. Sleep – Rest Pattern

According to Patient X, his sleep-rest pattern is disturbed due to the low back stiffness and

pain he was experiencing prior to his admission that’s been happening for four months already.

Along with that, his sleeping hours is inadequate for he only has 4-5 hours of sleep every night as

he worries what kind of condition he may have.

Norms:

Adults generally sleep 6-8 hours per night. About 20% of sleep is rapid eye movement.

The complete sleep cycle is about 1.5 hours in adults. Maintaining a regular sleep-wake rhythm is

more important than the number of hours slept. (Kozier et. al., Fundamentals of Nursing 7th

edition)
Analysis:

Patient X doesn’t meet the daily requirement of a normal sleep pattern which is around 6-8

hours. The low back stiffness and pain made him anxious every night which resulted to him not

being able to complete the right amount of hours that he needs according to his age.

XIII. State of Skin Aappendages

Patient X’s skin appendages were inspected beginning at the crown of his head, then

parting the hair to visualize the scalp, progressing caudally to his feet. It was seen that his hair is

equally distributed, no lice was shown, and pigmentation was consistent throughout the body. No

lesions, inflamation, vascular or other miscellaneous lesions observed. Patient has no wounds.

Skin’s color and characteristics was also assessed which showed a dry and a bit wrinkly skin due

to ageing. Skin turgor and capillary refill test was also done which showed a delay of three seconds

before going back to normal upon assessment.

Norms:

Normal skin is a uniform whitish pink or brown color, depending on the patient’s race.

Pallor is due to decreased visibility of the normal oxyhemoglobin. This can occur when the patient

has a decreased blood flow in the superficial vessels, as in shock or syncope, or when there is a

decreased amount of serum oxyhemoglobin as in anemia. No skin lesson should be present.

Normally, the skin is dry with a minimum respiration. It should be smooth, even and firm except

when there is a significant hair growth. It should return to its original contour when pinched.

(M.E.Z. Estes, Health Assessment and Physical Examination 3rd. edition). The normal Capillary

Refill Time (CRT) is <2 seconds; a CRT of >2 seconds suggests poor peripheral perfusion and

may be an early sign of shock (Hernández et al, 2020).

Analysis:

Patient X’s skin is tan and the color of his hair upon assessment is black with streaks of

white hair due to old age. No presence of infestation, infections, and wounds were also noted.

However, his skin is a little bit wrinkly and dry as we inspected in which these can be both

attributed to ageing and dehydration. These were seen when we performed a capillary refill and

skin turgor test that showed aberration of 3 seconds due to dehydration.