I.

Social Status

Patient X, a 25 year old male from Tarlac City.  According to the mother of the patient, He

usually stays in his room and plays computer games all day because he is not in good terms with his

family members and does not want to talk to anybody. He also eats his meals in his room. According

to one of their friends who was also involved, He occasionally bonds with friends because he is a

quick-tempered person who always ends up arguing with a lot of people.

Norms:

The ability to interact successfully with people and within an environment of which each

person is a part to develop and maintain intimacy with significant others and to develop respect and

tolerance for those with different opinions and beliefs are necessary determinants for a person’s

social state. The ability to achieve balance between work and leisure time is also a needed factor. A

person’s belief about education, employment and home influences personal satisfaction and

relationship with others (Kozier and Erb’s 2015).

Analysis:

Upon assessing Patient X, He does not have a good relationship with his family and

neighbors. He cannot interact successfully with people and within the environment during the

assessment. It was also added that he tends to be a troublemaker and stubborn in their barangay and

other social activities together with his friends. therefore, the patient’s social status is not normal.

II. Mental Status

 During the assessment of the patient's mental status, he is conscious, Patient X has a GCS

score of 14, verbalizing but not cooperative. He was having a hard time to state the date of the day

and place where he is, accurately and correctly due to pain and intoxication. He was not able to

follow instructions like raising his hands and he could not maintain his eye contact because of pain

he experiences. He is not well groom and clean his nails are full of dirt and his clothes is soaked with

blood and he appears to be weak and in pain. He was able to recall recent experiences and the fight

he experienced earlier. On the other hand, he had a hard time recalling about past experiences like

his childhood.

Norms:

The patient movement should appear relaxed with the appropriate amount of concern for the

assessment. The facial expressions should be appropriate to the content of the conversation and

should be symmetrical. The appropriateness and degree of affect should vary with the topics and the

patient’s cultural norms, and be reasonable, or eurythmic (normal). The patient should be able to

produce spontaneous, coherent speech. The speech should have an effortless flow with normal

inflections, volume, pitch, articulation, rate, and rhythm. Content of the message should make sense.

The attention of the patient should be able to correctly repeat the series of 5 numbers. The memory

of the patient should be able to correctly respond to questions and to identify all objects requested.

(Estes, 2011).

Analysis:

Based on the assessment, Patient X is awake, verbalizing but not cooperative. He did not

answered the present date and time correctly. The patient’s behavior appears to be distracted because

he could not maintain his eye-to-eye contact due to the pain on his right lumbar quadrant In terms of

general appearance, and the patient appears to be in pain as evidenced by facial grimace while
 guarding this abdomen. He acts and answers according to his age. His long-term memories were not

intact due to pain.

III. Emotional Status

Throughout the assessment, patient X appeared worried and nervous. Because of his situation, he was

silent and uneasy. He is drunk and unable to collaborate with us or respond to our questions. He was

crying due to pain. According to the mother of the patient he just recently broke up with his girlfriend few

days ago and cries in his room all day.

Norms:

Normally, the patient should have the ability to manage stress and to express emotion appropriately. It
also involves the ability to recognize, accept and express feelings and to accept one’s limitations. (Kozier
& Erb's, 2016).

Analysis:

Upon assessment the patient, Patient X was anxious and worried therefore, he was also crying due to
pain, the patient emotional status is not normal. Emotionally, stress can produce negative or
nonconstructive feelings about the self. Intellectually, stress can influence a person’s perceptual and
problem-solving abilities. Socially, stress can alter a person’s relationships with others. Spiritually, stress
can challenge one’s beliefs and values. (Kozier & ERB’s 2015)
IV. Sensory Perception

Sense of Sight

The following information were obtained in the assessment of the eye: sclera is white, the

conjunctiva is pale in color and pupils are equal round and reactive to light. Assesses of the 6 ocular

movements. The patient's eyes are round, moving symmetrically and his iris is dark brown.

Norms:

Normal vision of a person is 20/20 in a distance of 20 feet without wearing or using

eyeglasses or corrective grade lenses. (Estes, 2011)

Analysis:
 The patient’s sense of sight was noted also noted no alterations, sclera, conjunctiva, and pupil

are all in the normal state. Patient's eyes are round, moving symmetrically and his iris is dark brown

Therefore, a patient sense of sight is normal.

Sense of Smell

Patient X’s nose has no deviation in terms of shape and size, pointed nose and no discharges

seen during assessment.

Norms:

The nose must be symmetrical and along the middle of the face. Nostrils must be patent and

able to recognize the smell of different objects. (Estes, 2011)

Analysis:

Upon assessment the patient’s nose has no abnormalities and obstructions, therefore his sense

of smell is normal.

V. Motor Status

During the assessment, we ask the patient to squeeze my fingers, lift his leg while we press

down on his thigh, holding his leg straight and lift it against gravity, and flex and extend his foot

against our hand. The patient was able to squeeze my fingers but in a slow motion and no force. He

was not able to lift his leg due to the pain on his abdomen.

Norms:

Normal motor stability includes the ability to perform different activities. (Estes, 2011)

Analysis:

Based on the assessment, the patient motor status the patient shows signs of discomfort

because he was not able to hold his leg straight and lift it against gravity, and flex and extend his foot
 against my hand. He was not cooperative due to alcoholism and pain. With this, the patient motor

status is not normal.

VI. Temperature

Patient’s temperature was assessed upon arrival and a thermometer is placed on right axillary. The table
shown below shows the temperature obtained from the patient.

Date Assessed Time Temperature Analysis

09/18/22 2:00 am 37.5 C Normal

Norms:

The normal body temperature of a person is within 36.4 Celsius to 37.4 Celsius. (Estes, 2011)

Analysis:

Upon arrival, the temperature of patient X on his right axillary is in the normal range. This

indicates that the patient has no signs of febrile, and chill.