13 AREAS OF ASSESSMENT

1. Psychosocial and Psychological Status

- The patient is a 64-year-old female currently residing in Kayapa Proper, Nueva Viscaya with her children. Her religion
is Pentecostal, and has no practices or belief that might affect the procedures in providing health care. She is categorized
in the ‘Ego Integrity vs. Despair’ stage on Erik Erikson’s 8 stages of Psychosocial Development; she has shown positive
aging manifestations and despite his age and injury, she still has time to do some nature related activities like farming.
2. Mental and Emotional Status
- Patient is conscious, coherent, alert, and correspondent. She is very responsive in verbal impulses, noise, and light,
touch, pain stimuli and is ambulatory but still needs assistance when going to the comfort room. She is oriented to current
time, date, and place. She is very cooperative.
3. Environmental Status
- The patient is located in the Medical Ward and is familiar with the room set-up. She is oriented that she is in the
hospital-the patient is knowledgeable with regards to her condition and has an IV line located in her right arm in which
limits her general mobility. Bed rails are available for the patient together with disinfectants, drinking water, and food
located in her bed side table. There is steady pattern of activity and colour in her environment and it does not distract her.
4. Sensory Status
a. Visual Status
- There is visual deficit status like trouble distinguishing colors, loosing ability to see up close and needing more time to
adjust to changing level of light.
b. Auditory
- No corrective auditory deficits and no auditory device noted being used by the patient. She 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
- She is able to discriminate sweet, sour, salty, and bitter-taste from each other.
e. Tactile Status
- She is able to perceive heat, cold, pain, with regards to stimulus, able to differentiate common object by touch and able
to discriminate light and firm touch.
5. Motor Status
- Patient’s movements are limited due to old age. No prosthetics noted and all extremities are intact. She verbalizes that
her daughter was able to help her whenever she needs something.
6. Nutritional Status
- She was given a high in protein, rich in minerals and vitamins by the doctor and additional water. She has a poor appetite
and consumes at least 50% of the food served.
7. Elimination Status
- The patient defecated once and urinated 5 times during our shift on December 15, 2022. She has normal
elimination status until the end of our shift.
8. Fluids and Electrolyte Status
- She has an increase in consuming fluids for her hydration. She has an on-going 1L PLRS to run for 12 hours
located in her right arm.
9. Circulatory Status
- Pulses were normal with an observed regular heart rate and rhythm ranging from 70-75bpm. Capillary refill was normal
with 1-2 seconds.
TIME PR Capillary refill
 6:00 pm 75     1-2sec
10:00 pm 70 1-2sec

10. Respiratory Status

- Respiratory rate ranges from 18-21cpm, which was beyond the normal range for an adult (12- 20cpm). Oxygen
saturation (SpO2) ranges from 95%-99%
TIME RR     SPO2

6:00 pm 21       97%

10:00 pm 18     95%

11. Thermoregulatory Status

- His temperature ranges was 36.7degrees Celsius and skin was warm to touch. Temperature was taken via the axilla and
forehead. 
TIME TEMPERATURE
6:00 pm 36.7 ° C
10:00 pm 36.7 ° C

12. Integumentary Status

- Patient’s skin is fair and dry with no signs of lesions, rashes, pallor, jaundice, or cyanosis. Her hair is black with
highlights of white, well groomed, evenly distributed and no parasite infestations.

13. Sleep, Rest and Comfort Status

- The patient usually sleeps 7 to 8 hours a day prior to the accident. She sleeps at 10pm and wakes up usually at 6am.
During her hospital stay, she has appeared to be sleepy and is sleeping more than usual.