COR JESU COLLEGE, INC.
COLLEGE OF HEALTH SCIENCES
Tres De Mayo Campus, Brgy. Tres De Mayo, Digos City, Province of Davao
Del Sur
Website: www.cjc.edu.ph
NURSING ASSESSMENT
Submitted by: Tanutan, Rhenzes Hara R.
Submitted to: Sir Eddie Taneza
GUIDELINES PATIENT
I. MENTAL STATUS
a. State of mental Alert and quick to
consciousness respond to stimuli
b. Orientation Well-oriented to time,
place, person
c. Intellectual Able to recall events
capacity past and present,
understand and follow
instructions,
unimpaired remote,
recent and immediate
memory
d. Vocabulary level Able to speak local
dialect fluently
(Cebuano)
e. Attention span Attentive throughout
the assessment, good
attention span; able to
maintain attention
when having
conversation
f. Ability to Able to comprehend
understand ideas
II. STATUS OF SPECIAL SENSES
a. Auditory Can hear audibly
perception
b. Visual perception Good eyesight
DAY 1 DAY 2
Alert, responds Alert, responds
immediately and fully immediately and fully
to commands to commands
Patient was able to Patient recognizes that
recognize that he is he is currently
currently admitted at admitted to Gonzales
Gonzales Maranan Maranan Medical
Medical Center and Center, and identifies
identifies people people around him,
around him and his and is aware of the
present condition, and date and time.
knows the date and
time of the day.
Able to respond to Able to respond to
questions easily, questions easily,
recall past and present recall past and present
events and events and
understands understands
instructions. instructions.
Can understand local Can understand local
dialect and answers dialect and answers
briskly. briskly.
Able to maintain Able to maintain
attention when asked attention when asked
about information about information
about him. about him.
Normal reaction time Normal reaction time
is noted which speeds is noted which speeds
the time required to the time required to
grasp ideas. grasp ideas.
Able to hear normal Able to hear normal
voice tones and voice tones and
distinguished sound distinguished sound
clearly clearly
Vision is distorted, Vision is distorted,
 night vision is night vision is
decreased, and objects decreased, and objects
appear blurred. appear blurred.
Sensitive to bright Sensitive to bright
light. light.
c. Speech Coherent and proper Words are coherent Words are coherent
perception enunciation and comprehensible. and comprehensible.

d. Tactile Sensitive Partially good; unable Partially good; unable

perception to feel light touch to feel light touch
without pressure but without pressure but
is sensitive when is sensitive when
pressed deeply. pressed deeply.
e. Olfactory Can determine odour Able to smell and Able to smell and
perception distinguish different distinguish different
kinds of odor. kinds of odor.
III. MOTOR ABILITY

a. Current mobility Ambulatory without Non-ambulatory and Ambulatory without

assistance is on “Complete Bed assistance but with
Rest without limitation
Bathroom Privileges”
order.
b. Posture Good body Kyphotic in posture Kyphotic in posture
mechanics, normal due to age. due to age.
curvature of the spine
c. Range of joint Full range, partial, Able to ambulate Able to ambulate
motion none at all without assistance but without assistance but
was discouraged to was encouraged to
move frequently to limit strenuous
prevent further activities to prevent
complications related further complications.
to patient’s condition.
d. Muscle and nerve Sensation and motion Slightly sensitive Slightly sensitive
status present because skin tactile because skin tactile
receptors are reduced receptors are reduced
or altered. or altered.
e. Loss of None None None
extremities

IV. BODY TEMPERATURE

a. Ranges Ranges to 36 – 37°C 36.5°C 36.3°C

V. RESPIRATORY STATUS

a. Character No bubbling or stridor Crackles sound noted Crackles sound noted

RR:12-18 cpm upon auscultation RR: upon auscultation
15 cpm sound RR: 18 cpm
b. Use of None None None
respiratory aids

c. Interferences None None None

with respiration

d. Abnormal None None None

respiratory
opening
 VI. CIRCULATORY STATUS

a. Characteristic of Regular, strong, and Regular, strong, Regular, strong,

arterial pulse palpable bounding pulse, not bounding pulse, not
obliterated with obliterated with
pressure pressure
b. Blood Pressure 120/80mmHg 110/70mmHg 140/100mmHg

c. Apical-radial Regular within range 62 bpm 71 bpm

pulse of 60-100 bpm

d. Intravenous None Bottle #8; D5LR; Bottle #10; D5LR;

Fluid 1000mL; 80cc/hr 1000mL; 80cc/hr

VII. NUTRITIONAL STATUS

a. Condition of Can eat and chew DAT DAT

buccal activity food using mouth

b. Digestion of food
Able to digest food a DAT DAT
day
VIII. ELIMINATION STATUS

a. Bowel Eliminate 2-3 times a Without Bathroom Patient eliminated

day privileges. once.
b. bladder Not distended, able to Patient can urinate but Patient can urinate but
urinate was encouraged to was encouraged to
limit frequent moving limit frequent moving
and so bathroom to avoid further
privileges are complication.
discouraged as
tolerable.
c. abnormalities None None None

IX. MALE REPRODUCTIVE ORGAN

a. Prostate Gland Heart shaped, Admitting Admitting

symmetric, without
nodules with a weight
of approximately 20
to 25 g
X. STATE OF SKIN APPENDAGES
a. skin Warm, dry, with good
turgor, No abnormal
pigmentation,
bleeding, rash, or
other lesions.
b. hair
 Hair is coarse of fine
and shiny, no
presence of infestation
c. nails
Translucent, shiny
and firm in texture
Impression: Impression:
Prostatomegaly 26.9 g Prostatomegaly 26.9 g
Skin turgor has Skin turgor has
decreased. Deepening decreased. Deepening
of expression lines of expression lines
and wrinkling are and wrinkling are
observed. observed.
Hair is thin over the Hair is thin over the
scalp, unkempt with scalp, unkempt with
presence of noticeable presence of noticeable
grey hairs. No grey hairs. No
infestation but there is infestation but there is
presence of dandruffs. presence of dandruffs.
Intact, untrimmed, Intact, untrimmed,
and soiled nails are and soiled nails are
noted.  Tips of the noted. Tips of the
fingers are enlarged fingers are enlarged
and the nails curve and the nails curve
around the fingertips. around the fingertips.
 XI. STATE OF PHYSICAL REST AND COMFORT
a. sleep/rest pattern 8 hours Sleep disturbances Sleep disturbances
occur due to current occur due to current
condition. condition.
b. presence of None Patient reported a Patient reported
pain/discomfort 5/10 pain on the chest absence of pain
c. use of supportive None None None
aids
XII. EMOTIONAL STATUS
a. emotional Appropriate Patient is cheerful and Patient is cheerful and
reaction emotional reaction to cooperative to cooperative to
particular situations. procedures to be done. procedures to be done.
Positive in any way. Positive in any way.
b. body image Sympathetic and well Well-groomed and
Partially disheveled
groomed was to be discharged.
c. ability to relate Friendly and Cooperative, Cooperative,
to others approachable approachable, and approachable, and
conversed conversed
comfortably, comfortably,
cheerfully with his cheerfully with his
family and family and
interviewer. interviewer.
NURSING DIAGNOSIS

1. Risk for Decreased Cardiac Output secondary to Coronary artery Disease.

 SYSTEM ASSESSMENT

I. Central Nervous System

 Alert, responds immediately and fully to commands
 Oriented to time, date, people, and place

II. Respiratory System

 Crackles sound noted upon auscultation.
 RR within normal ranges

III. Musculoskeletal
 Kyphotic in posture due to age.
 Non-ambulatory and is on “Complete Bed Rest without Bathroom Privileges”
order. ROM: Full range on the upper extremities but has difficulty in flexing her
hips due to enlarge stomach.
 Slightly sensitive because skin tactile receptors are reduced or altered.

IV. Reproductive System

 Admitting Impression: Prostatomegaly 26.9 g

V. Gastro-intestinal System
 Diet As Tolerated
 (+) Bowel sounds

VI. Genitourinary System

 Patient refused

VII. Circulatory System

 BP of 110/70mmHg and 140/100mmHg
 HR of 62, and 71 bpm

VIII. Integumentary System

 Skin turgor has decreased. Deepening of expression lines and wrinkling are
observed.
 Hair is thin over the scalp, unkempt with presence of noticeable grey hairs. No
infestation but there is presence of dandruffs.