Patient’s Profile

Name: Patient baby

Age: 1year and 2months old
Sex: Male
Religion: Catholic
Ethnic Background: Igorot
Date and Time Admitted:
1. Admitting Diagnosis:

2. Final Diagnosis: n/a

13 AREAS OF ASSESSMENT

I. Phychological Status
patient baby is 1 year old and 2 months, born on September 11, 2020. He lives with his
parents and is currently residing at km6 la trinidad benguet. He is dependent in terms of
his health to her mother andother health care professionals. He and his family is a
Roman catholic and have no practices orbeliefs which might affect to providing health
care.

II. Mental and Emotional Status

patient baby is conscious and active. He is responsive in verbal stimuli, noise light, touch
and painstimuli. He acts according to his age. He is cooperative in terms of taking vital
signs. No socialconcerns or fears were noted and no medicines were taken to alter
emotional response.

III. Environmental Status

3. ENVIRONMENTAL STATUS
Patient was admitted at the pediatric ward with good lighting, congested due to
manypatients, with student nurses, staff nurses and doctors consistently monitoring
them,

IV. Sensory Status

a. Visual Status
There is no known visual deficit like color blindness.
b. Auditory
No corrective auditory deficits and no auditory device noted being used by thepatient. He
can also distinguish voices.
c. Olfactory Status
There is no presence of nasal flaring. The patient is able to distinguish an odor.
 d. Gustatory Status
He is able to discriminate sweet, sour, salty and bitter taste from each other.
e. Tactile Status
He is able to perceive heat, cold, pain with regards to stimulus, able to
differentiatecommon object by touch and able to discriminate light and firm touch.

V. Motor Status
He is active, his movements are not limited, he can walk, sit, and stand by himself. He
isable to move all his joints and can grasp or grab anything he wants.

VI. Nutritional Status

The patient’s food is being served in the hospital and sometimes he’s father and other
relatives bring in foods whenever they visit. He has a good appetite but he is picky of his
foods,if he likes the food then he eats a lot but if not her father has to persuade him to
eat just a little so that he can take his medications.

VII. Elimination Status

The patient eliminates in diaper once a day. The stool is usually brownish and semi-
solid. He drinks a lot of water as verbalized by father. During my shift the patient’s
elimination
status is:
Date Time Urine Stool
November,11, 2020 3pm

10pm URINE 1 STOOL 1

VIII. Fluids and Electrolytes

The patient has IVF OF D5LRS 500cc x 11hours infusing well over the right hand. The
patient drinks a lot of water as verbalized by
father. His skin turgor is normal and he has moist mouth and mucus membranes. The
patient’s
capillary refill is 1-2 seconds.

IX. Circulatory Status

X. Respiratory Status
XI. Temperature
DATE TIME CR RR TEMPERATUR
E

November,11, 6pm 105 32 36.4C

2022

10pm 99 30 36.5C
XII. Integumentary Status
Skin color is brownish and has a good skin turgor at 1-2 seconds. There are no wounds
noted or reported by the patient or his mother. Nails and hair are well kept by the
patient’s father.

XIII. Comfort and Rest Status

Patient can rest and sleep as long as his father is with him but sometimes being
disturbedby loud noises and when I take the vital signs and during time of giving
medication. father verbalize that the patient wants his father to be with him during sleep
even at home.