NAME: Paguirigan, Kryzza Leizel G.

DATE: 11/07/2021

SECTION: 2F-2A CLINICAL INSTRUCTOR: Crisanto Pulas

13 Areas of Assessment

1. Psychosocial and Psychological Status

Patient Leni is a 12-year-old female, a Roman Catholic and born on May 28, 2009, at Lourdes,
Baguio, City. She is currently living there with her mother and father. Her family belongs to the middle
class and all her medical expenses are being supported by her family. Erik Erikson’s Stages of
Psychosocial Development indicates that the patient falls under Identity vs. Role confusion. She is not
used to interacting with various individuals, and her family accepts all medical treatments and does not
believe in so-called "spiritual healing."

2. Mental and Emotional Status

The client is conscious, alert, coherent, oriented, and conversant. She is a 12-year-old female who
is currently enrolled in elementary. Patient’s chronological age is directly proportional to his
developmental age since he speaks and acts according to his age and maintains eye contact. During the
assessment, she is well oriented to time, location, and person, and she is capable of doing minimal ADLs.
She can respond adequately verbally and keep eye contact. The patient is appreciative of her parents for
their assistance.

3. Environmental Status

In Baguio City, she currently lives in a semi-concrete house with four rooms. The patient states
she is only staying in her room and is not going out. She shares her room with her oldest sister. The room
has 2 large windows which resulted in good ventilation. Their house is in a spacious area with lots of
trees. They have their water being delivered and their toilet facility is a water-carriage type. While in
hospital, Patient X is admitted and placed in pedia ward with quiet environment, an adequate lighting, and
air ventilation. Patient requested to be placed in a room with a big window so she could view outside, and
her request was granted.

4. Sensory Status

a. Visual Status

Eyes are almond in shape, irises are black in color, sclera is white, eyebrows and eyelashes are
evenly distributed. The conjunctiva is moist and pinkish. Her eyes can follow the six cardinal positions
and eyes were able to move in full range of motion in all directions.

b. Auditory

The patient can distinguish voices whether they are near or far. No corrective auditory deficits and
no auditory device noted being used by the patient. Patient was also able to repeat the whispered words on
both ears when the whisper test was conducted. He verbalized that he has no known auditory deficits nor
ear infection history and unusual sensations like ringing or buzzing.
c. Olfactory Status

Nose has no deviation in terms of shape and size. No discharges were seen during the assessment.
Orange peel and apple peel were used for this test and the patient was able to differentiate both smells
from each other signifying that there are no obstructions or abnormalities.

d. Gustatory Status

Her lips are dark in color and dry but symmetrical in shape. The tongue is darkish in color and
there is a presence of tooth cavities. For this test, the patient was asked to taste a pinch of salt and sugar
with his eyes closed and he was able to correctly identify both samples.

e. Tactile Status

Patient was asked to close her eyes and a cotton ball was used to stroke her neck, then, using
another cotton ball, the student nurse poured alcohol on it and rubbed it on the same area, and he stated
that he felt a wet and cold sensation on his skin. We also randomly introduced the sharp and dull ends of a
fork, and he was able to distinguish the sharp and dull ends. She is also able to differentiate common
objects by touch such as coins and papers by doing necessary procedures. Patient has an intact body
image.

5. Motor Status

The time, place and person of the patient was oriented. All the nerves were cranial and unchanged.
His top and bottom extremities were both normal. The tones, strength and reflexes of the muscles were all
good and normal.

6. Thermoregulatory Status

Date Time Temperature

Initial Vital Signs/Upon

Admission:
3:00 pm 38.8 °C
November 07, 2021

Upon Physical Examination:

November 07, 2021 4:00 pm 38.4 °C

7. Respiratory Status
 Date Time RR SPO2

Initial Vital
Signs/Upon
3:00 pm 43cpm 88.5 %
Admission:

November 07, 2021

Upon Physical
Examination:

November 07, 2010

4:00 pm 45cpm 89%

There were a presence of adventitious breath sounds upon auscultation.

8. Circulatory Status
Date Time CR Capillary BP

Initial Vital
Signs/Upon
Admission:
3:00 pm 154bpm 3 110/70mmHg
November 29,
2010

Upon Physical
Examination:

November 29,
4:00 pm 155bpm 2 110/ 75 mmHg
2010
lying and 110/80
mmHg standing

9. Nutritional Status

There are no food allergies in the patient. She has a weak appetite. It was difficult for her to swallow
her food and take her medications. When it comes to eating, she needs assistance. To avoid complications
in her case, she is provided protein-rich diets. In particular, the patient was recommended to increase her
fluid consumption for hydration.

10. Elimination Status

 Patient claimed that she urinates about 4-5 times a day. Passing urine/bowel open problem-free and
no excessive bleeding. There is considerable vomiting.

11. Sleep, Rest and Comfort Status

Prior to her hospitalization, the patient stated that she rests and sleeps for around 7-8 hours every
day. During the assessment, she indicated that she was unable to sleep effectively at night owing to a
continuous cough, shaking chills, and shallow breathing, which irritated her.

12. Fluids and Electrolytes Status

Hydration status was good. The patient drinks about 7 glasses of water per day.

13. Integumentary Status

During the assessment, she had good skin turgor, no history of skin allergies, no tattoo, bed sore, or
skin lesions, and her skin was warm to the touch. She's appropriately dressed, and her nails are clipped
short. Her hair is dark, thick, and short, with only a little dandruff visible. Cyanosis is present in the lips,
skin, and fingertips.