Monaliza B.

Ibañez
I. Social Status
Ms. Monaliza is a 15-year-old girl, born on May 24, 2006. She lives with her parents and
five siblings. Ms. Monaliza and her family are born Roman Catholic and does not have
any practices or beliefs which might affect to providing health care. She is currently a
high school student. She likes to help her mother and auntie in some household chores.
Norms:
Social status includes family relationships that state the client’s support system in
time of stress and in time of need. It meets a fundamental human need for social ties,
making life less stressful and social support buffers the negative effects of stress, thus
indicating indirectly contributing to good health outcomes. (Fundamentals of nursing,
Barbara Kozier, seventh edition)
Analysis:
Ms. Monaliza and her family are very close to each other.

II. Mental Status

Ms. Monaliza is conversant, coherent, alert, and responds appropriately to verbal stimuli.
She is well oriented to time, place, and person. She is able to show response to pain
stimuli. She sleeps about 9 hours a day. She acts according to her age, and she is able to
answer all the questions being asked during the interview.
Norms:
The client should be oriented to time and place, can identify past and recent memories
and should be able to verbalize concrete messages. The client’s ability to read and write
should match his educational level. The client should be able to respond to questions and
should be able to evaluate and act appropriately in situation. (Estez health assessment and
physical examination third edition.)
Analysis:
Ms. Monaliza is oriented to time, place, and person. She can identify recent memories
and she is able to verbalize concrete messages. Ms. Monaliza has a normal mental status.

III. Emotional Status

Ms. Monaliza stated that she has no problem when it comes to socialization. She doesn’t
take any medication to alter emotional response and she gets along well in her neighbors.
Norms:
 Young adult is a time of separation and independence from the family and of new
commitments, responsibilities, and accountability in social, work, and home relationships
and roles. (Health Assessment and Physical Examination, Mary Ellen Zator Estez)
Analysis:
At the age of 15, Ms. Monaliza already helps her parent in everyday chores. Like taking
care of her younger siblings and doing some house chores.

IV. Sensory Perception

 Sense of Sight
Assessment was done outside their house for adequate lighting. He is asked to sit holding
a notebook with a written word and was asked to read it, he is holding the notebook at the
normal distance and read it correctly. With the use of penlight, the following were
observed:
 Pupils constrict when struck by light
 Patient’s eyes are symmetrical and round
 Sclera is white in color
 Eyes are symmetrical in moving
Norms:
Normal distant visual acuity is 20/20 with or without corrective lenses. Eyeballs are
symmetrically aligned. The normal direct pupillary response is constriction. The sclera
should be white with some small blood vessels. Iris is typically round, flat, and evenly
colored. The pupil, round with a regular border, is centered in the iris. Ideal focus
distances for reading and writing average between 15 from the eyes. (Health
Assessment, Weber & Kelley, 2014)
Analysis:
With the given data, Monaliza’s visual acuity, extraocular muscle movements and
papillary response are normal.

 Sense of Taste
Ms. Monaliza was given two biscuits with different flavor and asked about the taste
which she differentiate correctly. Ms. Monaliza also stated that she can distinguish the
taste from candy, salt, and black coffee with no sugar and she prefers salty food.
Norms:
The client can distinguish between sweet and salty. (Health Assessment, Weber &
Kelley, 2014)
Analysis:
Ms. Monaliza’s sense of taste is normal.

 Sense of Hearing
For the sense of hearing, whisper test was performed. Ms. Monaliza was asked to repeat
the word that have been whispered in both ears. Whisper can be heard. When someone
calls her from afar, she can still hear them. No past illness with her hearing.
Norms:
The skin is smooth, with no lesions, lumps, or nodules. Color is consistent with facial
color. Normally the auricle, tragus, and mastoid process are not tender. Client can be
able to correctly repeat the two-syllable word as whispered. (Health Assessment, Weber
& Kelley, 2014)
Analysis:
Ms. Monaliza’s skin on ears are smooth, no lesions, lumps and nodules and the auricle,
tragus, and mastoid process are not tender. Overall, Ms. Monaliza’s sense of hearing is
normal.

 Sense of Smell
Ms. Monaliza was instructed to smell the provided perfumed and she identified it
correctly and she stated that she dislikes scents of storage room or Amoy kulod.
Norms:
Color is the same as the rest of the face and the nasal structure is smooth and symmetric.
The client must report no tenderness. Client is able to sniff through each nostril while
other is occluded. (Health Assessment, Weber & Kelley, 2014)
Analysis:
Ms. Monaliza’s nose was seen to be symmetrical, no tenderness and lesions seen. The
color is the same as the rest of the face. She was able to recognize the smell of the given
object. Her sense of small is normal.
 Tactile Sensitivity
Ms. Monaliza was instructed to close her eyes and states the part where she was touch.
She was also pinched in the area and Ms. Monaliza stated that she felt a pain in the
pinched area.
Norms:
Client correctly identifies area touched and point the touched area. Client feels and
reports pain. (Health Assessment, Weber & Kelley, 2014)
 Analysis:
Ms. Monaliza’s sensory transmission functions well, as shown by the data presented.

V. Motor Stability and Gait

Ms. Monaliza was able to stand on her own and balance herself during the assessment. She
can bend her shoulder apart, move it laterally and medially as well as rotate her shoulder in
the same manner. She can also bend her elbows and farther apart or rotate it laterally to face
upward and extending beyond the neutral position. She can also flex and extend her knee,
ankles, and feet, or tilting her feet inward and moving it toward and away the midline of her
body. Her neck is symmetrical with her head in central position.
Norms:
In standing position, the torso and head are upright. The head is midline and perpendicular to
the horizontal line of the shoulders and the pelvis. The shoulders and hips are level,
symmetry of the scapulae and iliac crests. The arms are freely from the shoulders. The feet
are aligned, and the toes point forward. Walking initiated in one smooth rhythmic fashion.
The foot is lifted 2.5 to 5 cm to the floor and propelled 30 to 45 cm forward in a straight path.
The client remains erect and balanced during all stages of gait and should be able to transfer
easily to various positions. There should be absence of discomfort during range of motion
exercise. (Health assessment and physical examination, mary ellen zator estez)
Analysis:
Ms. Monaliza’s gait and balance are coordinated, and her actions and movements are good
and normal for her age. She helps in house chores and taking care of her siblings. She also
works at their auntie in helping with chores. Overall, she is physically fit. She walks straight.
VI. Body Temperature
Date Assessed Time Temperature
September 18, 2021 3:00 pm 36.5 Celsius

Norms:

The normal body temperature ranges within 36°C and 37.5°C. (Fundamentals of
Nursing, Kozier & Erb, 10th Edition).

Analysis:

Ms. Monaliza’s body temperature is normal.