PATIENT’S PROFILE

Name: Mejia, Jaime Nationality: Filipino

Age: 80 y/o Religion: Roman Catholic
Birthdate: 05/25/1943 Civil Status: Married
Address: Asingan, Pangasinan
Admitting Diagnosis: AIDP ISCHEMIC CARDIDMYOPATHY ATRIALFIBRILLATION IN HEART FAILURE WITH
REDUCE EJECTION FRACTION HYPERTENSION STAGE2 CHRONIC VENOUSE ULCER

13 AREAS OF ASSESSMENT
I. PHYSIOLOGICAL AND PSYCHOLOGICAL STATUS
 Patient X is a 80-year-old male, married and a resident of Asingsn, Pangasinan. He lives with her 4
children and wife, their religion is Evangelist and they do not observe any religious practices that may
adversely affect to providing care. He appears anxious and worried about his condition. The watcher
verbalized no difficulty in interacting with other people and has a good relationship with her family.

II. MENTAL AND EMOTIONAL STATUS

 He is conscious, alert, and coherent. He speaks Ilokano, Tagalog, and English language. He is
confused to date, time, and place. He is responsive but with incomprehensive sounds and
cooperative, acts accordingly to his age and was able to express his feelings and concerns about the
complications.

III. ENVIRONMENTAL STATUS

 He is admitted to the ICU ward of Baguio General Hospital with bed # 9 having his daughter as his
watcher throughout his hospitalization. He was confined in a room with adequate lightning,
comfortable room temperature, and well-ventilated room.

IV. SENSORY STATUS

 Upon eye assessment, there was minimal visual deficits. He was then known to have a visual acuity
of 15/20. He was able to perform six cardinal gazes without any abnormalities noted. She was able to
perceive voice even from a distance with no corrective auditory deficits. He was able to distinguish
an odor from the other. Also, he has a poor sense of taste and was not able to distinguish sweet, sour,
salty, and bitter foods. With regards to tactile status, he was able to perceive sharp and dull, light and
firm touch, able to perceive heat, cold, pain in proportion to stimulus, and able to differentiate objects
such as pillow, blanket, and clothes.

V. MOTOR STATUS
 He is bedridden due to his current status. His movements are limited since he has been adimitted with
a complex disease. He was not able to walk even with assistance since balance is quite vulnerable
which indicates a risk for injury or fall. Requires assistance by the watcher in performing some
ADLs.

VI. NUTRITIONAL STATUS

 The food is being served in the hospital and patient feeds through NGT.
VII. ELIMINATION STATUS
 The patient eliminates in a diaper __2times a day___. The stool has an appearance of ___yellow and
tarry____. His urine is __dark yellow _____ in color. He drinks water via NGT to aid his elimination
and urinated good amount of _____ times during my shift.

VIII. FLUIDS AND ELECTROLYTE STATUS

 He usually drinks 500 ml of water daily and urinates regularly. He has an IVF of Pnss1L xKVO over
the left leg.
IX. CIRCULATORY STATUS
 Patient’s cardiac rate ranges from 90 to 125 bpm (normal range: 60-100 bpm) and blood pressure of
130/80-100/70 mmHg throughout the shift (normal range: 120/20 mmHg). This was taken while the
patient is lying down in the bed.

TIME CR BP
4 PM 96 bpm 130/70 mmHg
Aug 15, 2023
6 PM 111 bpm 120/70 mmHg
10 PM 108 bpm 100/70 mmHg

X. RESPIRATORY STATUS
 His respiratory rate was 17-24 bpm throughout the shift (normal range: 12 – 20 bpm) with no
abnormal breath sounds heard. His SpO2 ranges from 97% to 98% (normal range: 95% - 100%). The
result is a manifestation of effective breathing pattern.
TIME RR SPO2
4 PM 17 bpm 97%
Aug 15, 2023
6 PM 16 bpm 98%
10 PM 21 bpm 98%

XI. TEMPERATURE STATUS

 His axillary temperatures ranges from 36.6ºC to 36.7ºC (normal range: 36.5ºC to 37.5ºC). There is no
sign of profuse sweating or even irritated. The result is a manifestation of afebrile.

TIME TEMP
4 PM 36.9ºC
Aug 15, 2023
6 PM 36.7ºC
10 PM 36.6ºC

XII. INTEGUMENTARY STATUS

 Skin color is brownish and has a poor skin turgor at 2 seconds. The dressing is dry and intact and felt
pain when altering position. No lesions noted and capillary refill goes back 1-2 seconds. No jaundice
noted. Nails and hair are poorly kept. several tooth missing _.

XIII. COMFORT AND REST STATUS

 Patient was well rested on the bed at times but occasionally acts distressed due to difficulty of breathing