13 AREAS OF ASSESSMENT

I. SOCIAL STATUS

Patient Nino is a 29-year-old male, who lives in a 2-storey house in Tarlac

City together with his family. He is the oldest among his sibling and acts as the
breadwinner in the family because of the pandemic. He works as a manager in a call
center agency. His family helps him by doing house chores. According to him, he
loves to socialize with his friends and family during his free time and they always
support each other in times of need.

Norms:

The ability to interact successfully with people and within 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
which are necessary determinants for a person’s social state. (Kozier, 2015)

Analysis:

Patient Nino has a good social relationship with his family and friends. Social
status is normal.

II. MENTAL STATUS

Patient Nino looks lethargic and diaphoretic prior to the assessment but he was
able to answer our questions correctly despite having a difficulty of breathing. He
described his condition and stated that he feels weak and tired and he is worried about
his illness. He also stated his name, address, and the date of the day.

Norms:

The clients must be alert and awake with eyes open and looking at the
examiner and able to responds appropriately. (Weber, 2013)

Analysis:

The manner shows that the patient has a normal level of consciousness despite
his condition.
III. EMOTIONAL STATUS

Patient Nino stated that he feels anxious on not knowing how others will treat
him after they find out that he is HIV positive. He fears that it might affect his
relationship and communication with other people. Prior to his admission, he stated
that he thinks that there is no hope and that his condition will worsen.

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, 2018)

Analysis:

Patient Nino’s emotional status is not normal because he is experiencing fear

and anxiety regarding his current condition

IV. SENSORY PERCEPTION

Sense of sight

Patient Nino has a good eyesight and do not have reading glasses. His pupils
are equal, round, reactive to light and accommodation. Lens and sclera also no
deviation. He verbalized that he can see well and there are no disturbances about his
vision. His visual acuity of 20/20.

Norms:

The client who has a visual acuity of 20/20 is considered to have normal visual
acuity. The eyes must be symmetrical during the six cardinal gazes’ test. The sclera
should be white with some small blood vessels. Papillary constriction should occur
when struck by light. Ideal focus distances for reading and writing average between
15 inches from the eyes. (Estes, 2017)

Analysis:

Patient Nino has a good vision and his ocular muscle movements, visual
acuity and papillary response are normal.
Sense of taste

Prior to admission, the Patient Nino had an oral thrush that is present on the
tongue and inner cheeks and appears as white patches. He stated that when he is
eating his food, the taste is unpleasant and he often experience difficulty in
swallowing.

Norms:

A person can identify the taste of bitter, sweet, and sour. (Estes, 2017)

Analysis:

Patient Nino sense of taste is abnormal because he cannot distinguish the taste
due to the presence of oral thrush.

Sense of hearing

Prior to admission, there is no visible lumps or lesions noted, corrective

devices used such as hearing aids and discharges. Patient Nino verbalized that he can
hear well.

Norms:

For the auditory acuity, the patient should be able to hear the tick of the watch
2 inch away from the ear. (Estes, 2017)

Analysis:

Patient Nino’s auditory acuity is normal because he can distinguish voice even
from a distance, loud or soft.

Sense of smell

The patient has intact sense of smell as manifested by the ability to distinguish
familiar odor such as alcohol and coffee during assessment. No epistaxis was noted.
Nose was seen to be symmetrical, proportionate and no lesions seen.

Norms:
 Nose must be symmetrical and along the face. Each nostril must be patent and
recognize the smell of an object. (Estes, 2017)

Analysis:

Patient Nino has a normal sense of smell because he can distinguish foul and
fresh odor. Both nostrils are patent and no presence of obstruction.

Sense of Touch

Patient Nino facial sensations are intact and symmetrical on both sides. He is
able to perceived heat, cold and pain sensations. Upon assessment, we asked the
patient to distinguish the difference between a hot and cold test tube simultaneously
applied to both of his arms, the patient was able to identify which is hot and which is
cold.

Norms:

The skin contains receptors for pain, touch, pressure and temperature. Sensory
signals are transmitted along rapid sensory pathways, and less distinct signals such as
pressure of localized touch are sent via slower sensory pathways. (Estes, 2017)

Analysis:

Patient Nino’s tactile sensitivity is normal because he was able to respond to

touch, pain and temperature during the assessment.

V. MOTOR STATUS

Prior to admission, the patient requires assistance from his family member
when standing up and when walking because he cannot stand alone due to his feeling
of weakness. He avoids moving around because it makes his breathing more difficult.

Norms:

Normal motor stability includes the ability to perform different activities

without causing pain and discomfort. It should be firm and have coordinated
movements. (Estes, 2017)
 Analysis:

Patient Nino motor stability is not normal because gait and balance were not
fully coordinated due to his weakness. And he cannot perform activities of daily
living without assistance.

VI. BODY TEMPERATURE

Prior to admission, the patient’s axillary temperature is 37.9°C and he

verbalized feeling of warmth and cold. The room is adequately ventilated and the
patient is wearing clothes made of cotton not greatly affecting his temperature.

Date Assessed Time Temperature Analysis

July 18, 2021 8:00 am 39 °C abnormal
July 18, 2021 12:00 pm 37.3 °C normal
July 18, 2021 4:00 pm 36.5 °C normal
Norms:

Normal axillary temperature is within 34.4°C to 37.4°C. (Estes, 2017)

Analysis:

Patient Nino body temperature is above normal range due to the presence of
infection. He is lethargic and warm to touch.

VII. Respiratory Status

When the patient auscultated in lungs, the patient has poor inspiratory effort
and bibasilar crackles 2/3 of the way up the posterior lung field. He had a tachycardia
but no murmurs.
Norms:
Normal respiratory rate for adults is 12-20 cpm. Average is 18. In terms of
pattern, normal respirations must be regular and even in rhythm. The normal depth of
respirations is non-exaggerated and effortless. (Health assessment and physical
examination 3rd edition by Mary Ellen Zator Estes).

Analysis:
 Patient X has an abnormal breath sound. His inspiratory effort is poor and
have a bibasilar crackles 2/3 of the way up to the posterior lung field. The patient is
tachycardic, but no murmurs.

Date Assessed Time Respiratory rate

July 18, 2021 8:00 am 30
VIII. Circulatory Status

During the assessment of his capillary refill, his nail beds returned to its
original color after 2 seconds. His blood pressure is within in normal range. His heart
rate is slightly elevated with a 112 beats per minute.

Norms:

The normal cardiac rate or pulse rate of an adult is 60-100 bpm. The average
blood pressure of a healthy adult is 110 to 120 systole 70 to 80 diastole. The normal
capillary refill test is 2-3 seconds and upon capillary refill test was done and it returns
to normal state within 2-3 second. (Kozier, Fundamentals of Nursing 7th Edition.)

Analysis:

The data given below shows that patient X’s heart rate is increased. The blood
pressure and capillary refill is in the normal range.

Date Assessed Time Heart Rate Blood pressure

July 18, 2021 8:02 am 112 110/70

IX. Nutritional Status

Patient X claims that he has a daily intake rice, fish and meat. Sometimes
fruits and vegetables. He eats 2-3 times a day and drink 8 glasses of water. Sometimes
he cannot eat his proper meals per day because of his work.

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
dairyproducts; 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. Fluid
intake is on the average of 8-10 glasses per day (Mohan, 2002).

Analysis:

Patient X has a normal nutritional intake. He eats what the prescribed or the
normal meal of the day.

X. Elimination Status

Patient X claimed that he usually defecates once a day with semi solid
consistency, brownish in color and normal amount in elimination. He voids 3 times a
day, light yellow in color with normal amount.

Norms:

The typical adult bowel movement consists of a moderate amount of formed,

brown stool that is passed without difficulty. The normal frequency of bowel
elimination varies from several stools per day to only two or three per week. Most
adults experience bowel elimination every 1 to 2 days. Normal voiding is 3 to 4
times a day with an output of 1200 to 1500 ml a day. Urine is clear to yellowish
in color. (Fundamentals of Nursing, kozier, 2007)

Analysis:

With regards to Patient X’s elimination status, it appears that his elimination
and voiding pattern is within normal.

XI. Reproductive Status

Patient X was circumcised at 10 years old. He didn’t undergo to any surgery

for sterility, and doesn’t have any disease pertaining to his genitalia. Upon admission,
there were no abnormalities noted and there are no presence of discharges, lesions,
and tenderness upon palpation and other deviations from the genitals and its
surrounding area and the pubic hair is well distributed.

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:

Based from the data, Patient X reproductive status is normal. There are

no assessed significant deviations from normal seen from the patient’s reproductive
status

XII. SLEEP REST PATTERN

Patient X’s stated that he usually sleeps 7 to 8 hours a day. He usually sleeps
at 2am and wakes up at 10am. He usually watches television or playing mobile games
at home during rest hours.

Norms:

Sleep refers to altered consciousness with general slowing of physiologic

process while rest refers to relaxation and calmness, both mental and physical. A
typical sleeper will pass through 7 to 9 hours of sleep and take a rest using home
relaxation activities such as reading, telling stories and others. (Nursing
Fundamentals by Rick Daniels)

Analysis:

Patient X has a normal and adequate sleep pattern, even though he sleep at
late night because of his work, he was able to sleep 8 hours when he got home.
XIII. STATE OF SKIN APPENDAGES

Patient X is pale and diaphoretic due to his condition and these are one of the
symptoms of a person with a HIV. Unhealthy pale appearance to the palpebral
conjunctiva is present as evidenced by the CD4 count result.

Norms:

Obvious changes occur in the integumentary system (skin, hair, nails) with
age. The skin becomes drier and more fragile, the hair loses color, the finger nails and
toe nails become thickened and brittle, and in man over 60, facial hair increases.
These integumentary system changes accompany progressive losses of subcutaneous
fat and muscle tissue, muscle atrophy, and loss of elastic fibers. (Fundamental of
Nursing 7th Edition by Barbara Kozier)

The palpebral conjunctiva should appear pink and moist. Normally, the skin is
a uniform whitish pink or brown color, depending on the patient’s race. Normally, the
nails have a pink cast in light-skinned individuals and are brown in dark-skinned
individuals. (Health Assessment and Physical Examination 3rd Edition by Mary Ellen
Zator Estes)

Analysis:

Based from the above information, the patient skin of appendages is not
normal because of the signs and symptoms. HIV symptoms is starting to appears in
the patient.