NURSING ASSESSMENT

Date: _June 29, 2021___________

I. General Information
Name of Patient: Cesar Bustillo Height: ___ cm Weight: ____ kg
Address: P-19, Alviola Village, Butuan Ciity Age: 80 years old Gender: Male
Marital Status: Married Name of Spouse:Carolina Bustillo
Number of and ages of children/siblings:
The patient mentioned that he has 5 children and 10 grandchildren.
Occupation of Patient: Retired salesman representative
Include and specify past occupation and reason of change of occupation: N/A
Educational Attainment: College degree Religion: Roman Catholic
Arrests, Court Dates, Probation: N/A

II. Initial Parameters

Vital signs: BP 100/60 mmHg Temp: 36.5 degree Celsius PR: _75_ bpm RR: 15 bpm
Allergies to food, drug, etc. (Please specify in RED ink) Client has no unknown allergies
to food and drug.
Use of street drugs:
___N/A___________________________________________________
Use of alcohol (Specify the amount, when it started, how it started and history of
blackouts:
__N/A___________________________________________________________
______________________________________________________________________

III. Current Status

A. Physical characteristics (Describe the apparent age, manner of dress, hygiene,
posture, gait, gestures, facial expression, mannerisms, behavior during
interaction) Client C is a 80 year old man. Who is oriented, well-groomed, and
dress appropriately according to age and occasion. Patient is neat and clean.
Patient is sitting erect. Patient is able to maintain eye contact. Facial Expressions
are congruent towards the manner of speaking. Patient is responsive and
cooperative throughout the interview.
B. Speech
Soft: __/__ Hesitant: ____ Pressured: _____ Mumbled: _____Loud: ____
Slurred: ____Rapid: ____ Whispered: ____ Others
(Please Specify): _____________________
Does his/her style of vocabulary convey:
Coyness: __ Arrogance:___ Superiority: ___ Pretentiousness:___
Suspiciousness: ____Secretiveness: ____ Humor: ____
Others (Please specify): Serious

Does he/she use speech to:

Plead:____Command:____Shock:____Frighten:____Seduce:____Intimidate:___
Others (Please specify):___N/A_
C. Stream of Talk
 Spontaneous:__/__Deliberation of talk: _________________________________
(Please write the actual statement)
Organization of Talk:
Relevant: SN: “unsa man imong ge bati karon tay?” Client: “Okay raman ko.
Usahay maka feel ko sakit saakong tiyan.”
Irrelevant: N/A
Incoherent: N/A
Looseness of association: N/A
Flight of Ideas: N/A
Tangential: N/A
Circumstantial: N/A
Perseveration: N/A
Clang Association: N/A
Neologism: N/A
Echolalia: N/A
Echopraxia: N/A
Others, specify: ___________________________________________________

IV. Mood and Affect

Mood
Euthymic:__/__ Euphoric: ____ Anxious: ____ Angry: ____ Depressed: _____
Irritable: _____ Terrified: _____ Empty: ____ Guilty: ____
Others (Specify) ___________________________________________________
Affect
Blunt: ____ Flat: ____ Depressed: ____ Fearful: ____ Angry: ___ Elated: ____
Others (Specify) N/A
Range of affective expression?
Consistent____/_______Anhedonic: ____________Labile:__________________
Appropriate to the situation and feelings verbalized ______/__________________
Others (Specify) ___________________________________________________

V. Perception
(Please write the actual statement)
Hallucination (Please specify what type): _____N/A______
Delusion (Please specify what type): _____N/A_____
Illusion: ______N/A_____
Derealization: _N/A__________
Depersonalization: ___N/A________________________
Identification: _____N/A_______________
Thought broadcasting: _____N/A____________
De ja vu: ____N/A_________
Jamais vu: ____N/A_______

VI. Orientation and Memory

(Please write the actual statement)
Orientation
1. Does the client identify the date correctly? _N/A
Can he/she estimate the time of the day? N/A
The month and year? N/A
2. Does the client know where he/she is? SN:” Tay, kabaw ka aha ta karon?” Client: “Oo,
nagpuyo ko sa Alviola Village, sa Purok-19.”
3. Does the client know who the examiner is? The student nurse, introduced herself
before having the actual interview.
Is he aware of the roles or names of the people with whom he/she is in contact with?
The patient express that he is living together with his wife and 3 grandchildren.
Memory
Recall of remote past experience: SN: “Tay, naka dumdum ka when tong inyong kasal?”
Client: “Decemeber 22, 1969
Recall of recent past memory: SN: “Tay, naka dumdum paka aha ka nag skwela tong
elementary paka?” Client: “Ban elementary school ”
Recall of recent memory/present events: SN:” Tay, unsa imong ge kaon gaina buntag?”
Client: “kan on og isda”

VII. Content of Thought

(Please write the actual statement or describe the situation/circumstances that will
support your assessment)
Preoccupation with illness: SN:” unsa imong thought about saimong sakit tay?” Clint:
“Dawat naman nako ni akong sakit.”
Compulsions/Obsessions: N/A
Phobias: SN: “ Naa bata mga kahdlok ron tay? Labi na saimong sakit?” Client: “Wa
Homicidal ideation: N/A
Suicidal Ideation: N/A
Specific Antisocial Urges: N/A
Concentration (Is the client able to sustain attention over an extended period of time?
Yes, the patient was able to listen attentively and answered the questions accurately.
Judgement (Is the client aware of the probable consequences of his social behavior? Test
judgement by asking the client what he would do in an imaginary situation)
SN: “Tay, if nag away imong mga anak, unsa imong buhaton?” Client: “Ako silang
sturyahon tong anak nako nga nagaway kung unsa ang problema aron maka solbad
dayon”

VIII. Awareness
(Please write the actual statement or describe the situation/circumstances that will
support your assessment)
Client perception or meaning of current mental illness and causes: N/A
Beliefs about illness and health: SN: “Naa baka kahadlok or kabalaka na imong ge bati
labi na naa ka cancer?” Client: “Wala naman, nadawat naman nako pod, og ako naman
ge salig sa Ginoo ni. Og naa pod akong mga anak ga supporta saako karon.”
Client’s attitude or beliefs towards hospitalization and health care personnel: SN: “Karon
tay, unsa man imong gibuhat labi na saimong sakit karon?” Client: “Ga chemo gihapon
ko ron 4 years na, unya tumbar mga tambal nako sa cancer og saakong highblood.”
Client expectation and goals for current hospitalization: SN:” Unsa man imong mg age
buhat karon bahin sa aimong sakit?” Client: “Padayon lang gehapon ko sa routine unya
nag-ga ampo lang gehapon ko nga mayo ko ani nga sakit sa Ginoo.”
Coping skills used: SN: “Unsa pamn lain pamaagi imong ginabuhat tay if naa ka
problema?” Client: “Mag-ampo ko sa Ginoo.”
Frequency and types of physical complaints: SN: “Unsa man imong gipang bati karon
tay?” Client: “N adiagnose man ko og colon cancer, so naa koi bati on nga mga sakit sa
tiyan usahay unya ang sakit kay naa sa 5-6”
Client’s opinion of himself (who he/she is, value of own life): SN: “Tay, naa paba kay mga
unaccomplished task?” Client: “Wala na kay nanaghuman na akong mga anak unya
nabuhat na nako tanan, ang ako lang kay 5 years pa pangayo sa Ginoo kay aron maka
tabang pako diri sa balay.”

Submitted by:
Cecelle May B. Butao