PATIENT PROFILE: Mr. Cupas Lorenzo, an 82-year-old Ibaloi male, suffered his first stroke last month.

He currently presents with comorbidities including peptic ulcer,

hypertension, and upper gastrointestinal bleeding. Mr. Lorenzo experiences significant mobility challenges, being bedridden with lower extremity muscle weakness. He relies on an
Intra Foley Catheter, nasal cannula for oxygen support, and IVF PNSS 1L.
NAME: Cupas, Lorenzo
AGE: 82
GENDER: Male
CIVIL STATUS: Married
RELIGION: CAR
ADMITTING DIAGNOSIS: Upper gastrointestinal Bleeding Sec. Peptic Ulcer Disease Sec. Hypertension
DATE AND TIME ADMITTED:

13 AREAS OF ASSESSMENT

I. Psychosocial and Psychological Status

Mr. Lorenzo, married with six children, expresses longing for his offspring. He receives dedicated care from his two sisters and one brother.

II. Mental and Emotional Status

Mr. Cupas Lorenzo presents with reduced attentiveness, displaying signs of decreased focus and concentration. He is responsive to verbal cues, though may require repetition. He exhibits a
decreased response to environmental auditory and visual cues. Despite this diminished sensitivity, he engages with the environment to the best of his ability. Mr. Lorenzo demonstrates
cooperation and effort to engage in conversations. So we have to adapt communication strategies to accommodate his reduced attentiveness.

III. Environmental Status

Mr. Cupas Lorenzo's environment is characterized by a hospital setting. The room maintains a consistent rhythm of movement, with mild noise levels. Lighting conditions are normal so they do
not cause discomfort. His surroundings are organized to provide easy accessibility to food and drink, placed on his left side. However, Mr. Lorenzo faces challenges in achieving restful sleep due
to the nature of his condition and the activities related to his care.

IV. Sensory Status

a. Visual Status:

Mr. Lorenzo exhibits blurred vision without glasses, responsive pupils to light when used by a penlight, and it is symmetrical and spherical the sclera is pale as well as the conjuctiva. His eyes
were able to move in a full range of motion as she followed the path of a finger with his eyes in six cardinal positions.

b. Auditory Status:

No nasal issues observed, maintaining olfactory discrimination between scents.

c. Olfactory Status:

There is no nasal flaring or discharges, and her nose is symmetrical. On palpation, there is no discomfort or lesions. The patient can tell the difference between fragrances he is given, such as
alcohol and Food.

d. Gustatory Status:

Capable of discerning tastes, including sour, sweet, and bitter, despite dry lips and pale tongue.

e. Tactile Status:

Unable to distinguish sharp from dull sensations on forearm.

V. Motor Status

Mr. Cupas Lorenzo's motor status reflects significant limitations in mobility due to lower extremity muscle weakness. As a result, he is currently bedridden and reliant on assistance for
movement. Despite these challenges, there is no indication of prosthetic device usage, and all limbs remain intact.

VI. Thermoregulatory Status

The following temperature ranges were measured using the axilla.

Date Time Temperature

October 19, 2023 3 pm 36.4
 6 pm 36.6
10 pm 36.6
October 20, 2023 3 pm 36.6
6 pm 36.5
10 pm 36.5
October 21, 2023 3 pm 36.2
6 pm 36.4
10 pm 36.5

VII. Respiratory Status

The patient is tachypneic upon admission due to the pain that she was feeling

Date Time RR SPO2\

October 19, 2023 3 pm 21 95
6 pm 19 98
10 pm 20 98
October 20, 2023 3 pm 19 95
6 pm 23 95
10 pm 21 96
October 21, 2023 3 pm 21 96
6 pm 22 96
10 pm 21 95

Date Time RR SPO2

VIII. Circulatory Status

Adults' normal heart rates vary from 60 to 120 beats per minute, with the patient falling into the abnormal range of 120 beats per minute. In 1-2 seconds, her capillary refill returns to normal
levels.

Date Time CR Capillary

 October 19, 2023 3 pm 115 bpm 1-2 seconds
6 pm 119 bpm 1-2 seconds
10 pm 100 bpm 1-2 seconds
October 20, 2023 3 pm 98 bpm 1-2 seconds
6 pm 97 bpm 1-2 seconds
10 pm 102 bpm 1-2 seconds
October 21, 2023 3 pm 94 bpm 1-2 seconds
6 pm 97 bpm 1-2 seconds
10 pm 91 bpm 1-2 seconds

IX. Nutritional Status

Prior to admission, the watchers indicated that he was not able to complete his meals sue to his condition.

X. Elimination Status

Mr. Cupas Lorenzo is currently experiencing constipation, characterized by infrequent bowel movements and difficulty in passing stool. This altered elimination pattern deviates from his usual
routine.

XI. Sleep, Rest and Comfort Status

Prior to being admitted to the hospital, the patient has not been getting his sleeps well. However, due to his condition, the watchers reports that his sleep is interrupted by nurses taking his vital
signs or administering drugs, as well pains on left side of his abdominal area, and right knee.

XII. Fluid and Electrolyte Status

The patient typically consumes just 3-5 glasses of water each day; fluid intake has decreased. he has less urinary frequency, which means he urinates does not often throughout the day.

XIII. Integumentary Status

Mr. Cupas Lorenzo's integumentary assessment reveals a patient with a light brown complexion. His skin exhibits slight dryness, and his lips are notably dry. However, no visible blemishes or
rashes are noted. His short, dark, and thin hair is devoid of lice or dandruff. Capillary refill time is within the normal range, occurring in 2-3 seconds.