NAME: Cantoria, Philippe N. c.

Olfactory Status
DATE: December 10, 2022 The nose has no deviation in terms of shape and size. No discharges were seen
13 Areas of Assessment during the assessment. There are no obstructions or abnormalities.

1. Psychosocial and Psychological Status d. Gustatory Status

The patient is a male newborn, a Roman Catholic, born on December 9, 2022, in La His lips are pinkish in color and symmetrical in shape. The tongue is whitish in color
Trinidad, Benguet. He is currently living there with her mother and father. His family belongs and there is no presence of a tooth.
to the middle class and all his medical expenses are being supported by her family. Erik
Erikson’s Stages of Psychosocial Development indicate that the patient falls under Trust vs. e. Tactile Status
Mistrust. During this stage, the infant is uncertain about the world in which they live and The patient reacts to external stimuli like the rooting reflex when the cheek is
looks towards their primary caregiver for stability and consistency of care. touched.

2. Mental and Emotional Status 5. Motor Status

The client is conscious, alert, coherent, oriented, and conversant. He is a newborn male His top and bottom extremities were both normal. The
who is currently in the care of Benguet General Hospital’s healthcare professionals and his tones, strength, and reflexes of the muscles were all good and normal.
parents. The patient’s chronological age is directly proportional to his developmental age
since he acts according to his age. He can respond to reflexes suitable to his age. 6. Thermoregulatory Status
DATE TIME TEMPERATURE CONCLUSION
3. Environmental Status December 09, 2022 Initial V/S 36.5 °C >Patient is afebrile.
In La Trinidad, he currently stays in the hospital in a bed in one of the cubicles in the 3 pm
OB Ward where his mother was admitted. The patient is not going out. He shares December 09, 2022 7PM 36.5°C >Patient is afebrile.
the bed with her mother. The cubicle has access to large a window which resulted in December 09, 2022 9 PM 36. 7°C >Patient is afebrile.
good ventilation and has adequate lighting. His father buys water in a nearby store, and the
Hospital’s comfort rooms and shower rooms are quite good in condition. 7. Respiratory Status
DATE TIME RR SPO2
4. Sensory Status December 09, 2022 Initial V/S 30 97%
a. Visual Status 3 PM
Eyes are almond in shape, irises are black in color, the sclera is white, and eyebrows December 09, 2022 7 PM 49 98%
and eyelashes are evenly distributed. The conjunctiva is moist and pinkish. December 09, 2022 9 PM 51 98%

b. Auditory There was no presence of adventitious breath sounds upon auscultation.

The has no corrective auditory deficits and no auditory device was noted being used
by the patient. He has no known auditory deficits or ear infection
8. Circulatory Status 12. Fluids and Electrolytes Status
DATE TIME CR CAPILLARY Hydration status was good. The patient drinks about 7 glasses of water per
December 09, 2022 Initial V/S 131 2 day.
3 pm 13. Integumentary Status
December 09, 2022 7 PM 139 2 During the assessment, she had good skin turgor, no history of skin allergies,
December 09, 2022 9 PM 138 2 no tattoo, bed sore, or skin lesions, and her skin was warm to the touch. She's
9. Nutritional Status appropriately dressed, and her nails are clipped short. Her hair is dark, thick, and
There are no food allergies in the patient. She has a weak appetite. It was short, with only a little dandruff visible. Cyanosis is present in the lips, skin, and
difficult for her to swallow her food and take her medications. When it comes to fingertips
eating, she needs assistance. To avoid complications in her case, she is provided 12. Fluids and Electrolytes Status
protein-rich diets. In particular, the patient was recommended to increase her fluid The hydration status of the Patient is good. The patient breastfeeds every 2 hours as
consumption for hydration. per instructed by the student nurse, i.e., Me.

9. Nutritional Status 13. Integumentary Status

His main diet is exclusively breastmilk which provides him with the nutrients and During the assessment, he had good skin turgor, no known skin allergies,
hydration that he needs for development. no tattoos, bed sore, or skin lesions, and his soft and bouncy. He’s appropriately dressed, and
his nails are short. His hair is dark and
10. Elimination Status short, without dandruff in sight. There is no cyanosis is present in the lips, skin, and
Patient claimed that she urinates about 4-5 times a day. Passing urine/bowel fingertips.
open problem-free and no excessive bleeding. There is considerable vomiting. 10. Elimination Status
11. Sleep, Rest and Comfort Status Patient claimed that she urinates about 4-5 times a day. Passing urine/bowel
Prior to her hospitalization, the patient stated that she rests and sleeps for open problem-free and no excessive bleeding. There is considerable vomiting.
around 7-8 hours every day. During the assessment, she indicated that she was 11. Sleep, Rest and Comfort Status
unable to sleep effectively at night owing to a continuous cough, shaking chills, and Prior to her hospitalization, the patient stated that she rests and sleeps for
shallow breathing, which irritated he around 7-8 hours every day. During the assessment, she indicated that she was
10. Elimination Status unable to sleep effectively at night owing to a continuous cough, shaking chills, and
DATE TIME URINE STOOL shallow breathing, which irritated her.
December 09, 2022 3 PM-11 PM 3 3 12. Fluids and Electrolytes Status
DURING THE Hydration status was good. The patient drinks about 7 glasses of water per
SHIFT day.
13. Integumentary Status
11. Sleep, Rest, and Comfort Status During the assessment, she had good skin turgor, no history of skin allergies,
The patient sleeps most of the day. He spends about 16 hours a day sleeping and wakes no tattoo, bed sore, or skin lesions, and her skin was warm to the touch. She's
up when stimulated by external stimuli, hungry and needing to breastfeed, and when a appropriately dressed, and her nails are clipped short. Her hair is dark, thick, and
healthcare professional is doing an assessment. short, with only a little dandruff visible. Cyanosis is present in the lips, skin, and
fingertips.
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.