Mendoza, Jopher

Encomienda, Justine Kate

Piggangay, Grace

13 Areas of Assessment

I. Psychological
Ms. Mariano is 25 years old and single. She is currently residing in Middle Rock Quarry
Baguio City. She is a registered nurse and working as a hemodialysis staff at a private
institute here in Baguio City. She practices healthy lifestyle as she is conscious with her
health in which she needs in her line of job. Her religion is Roman Catholic. During her spare
time, she usually spends time with her family and sometimes would go out and catch up
with her friends. She has an optimistic view in life. (dvt stat)

II. Mental and emotional status

The patient is very conversant and cooperative. She responds very well in environmental
stimuli like noise, to pain, light and answers questions in a correlational manner. She is
oriented to date, time, and place. No noted social concerns and she doesn’t have any
ongoing medications regarding her health status. She verbalized that she is a little exhausted
due to the current pandemic that we are facing.

III. Environmental status

There are no observed sensory deficits and oriented on where she is. She is living in an area
wherein cleanliness is observed. Garbage bins are in a segregated manner. She has a well-
organized variety of furniture. The water supply of her home is clean because it is supplied
by the city water district and drinking water is being delivered which is safely filtered. No
signs of breeding sites of vectors. She sleeps at least 5-6 hours in a day.

IV. Sensory status

No noted visual deficits like color blindness however she has astigmatism which had been
diagnosed last month. She can differentiate the certain colors in her environment. No
auditory problems as evidence by she can distinguish sounds in her surroundings. Also, no
gustation deficit because she can determine sweet, salty, sour and bitter. In accordance to
tactile aspect, she can tell apart sharp and dull objects and light to firm touch. She can also
perceive heat, cold and pain. In addition, she can identify objects that are being presented.
She has an intact body image and abnormalities.

V. Motor status
She has a good range of motion. She has a good gait while walking and have a good sense of
balance. She can present facial expressions and no indication of any facial disorders. She has
a good posture, and she has good control of her skeletal muscles per command
VI. Nutritional status
The patient usually eats 3-4 times a day. Fish, vegetables, and fruits are incorporated in her
diet. According to her she avoids fatty foods to prevent her family health history which is
hypertension. She drinks a lot of water, and her skin is smooth and with fair complexion.
Nails are trimmed. Has no family or religious practices that affects her dietary practices.

VII. Elimination status

She has a good normal bowel pattern and has a well-formed brownish stool color. She
urinates regularly and it is yellow in color and in adequate amount. No other abnormalities
noted.

VIII. Fluid and electrolyte status

She drinks almost 2 liters of water in a day. Her skin turgor is normal and has a moist mouth
and mucous membranes. Also has a good capillary refill of 1-2 seconds.

IX. Circulatory status

Has a good capillary refill of 1-2 seconds. Heart rate is in normal range with 70- 87 beats per
minute and is normal in rhythm. No clubbing of fingers. There are no palpable diminished
pulses in any other extremities. No abnormal heart sounds are present. Her blood pressure
is 110/60mmhg which is taken while she is sitting.

X. Respiratory status
Her respiratory ranged at 16-20cpm which is normal. No noted use of accessory muscles.
No abnormal breath sounds, and lips is pinkish in color.

XI. Temperature
She has a body temperature of 36.8 °C which is normal for her age and taken via axillary. No
signs of distress. The environment temperature is cold and humid, and she doesn’t complain
regarding about her surrounding’s temperature.

XII. Integumentary status

She has a good skin turgor and skin is evidently moist. No other break in skin integrity
observed. Nails and hair are kept well.

XIII. Comfort and rest status

She sleeps 5-6 hours in a day however there are some instances that she gets her rest less
than the stated number of sleep hours.