1.

Psychosocial Status

The patient is a 47-year-old resident of Commonwealth, Quezon City. She works as an accountant. Her
family status is not mentioned. She is currently married with 4 children. She is a practicing Catholic and is
an active member of her church community. During the assessment, the patient expressed concerns
about her menopausal symptoms affecting her personal and professional life. She reported feeling
irritable, anxious, and having difficulty sleeping. She also stated that she has been experiencing mood
swings and hot flashes, which have impacted her overall quality of life.

2. Mental and Emotional Status

The patient appeared alert and oriented to time, place, and person. She was able to respond
appropriately to verbal and non-verbal stimuli. The patient reported feeling overwhelmed by her
menopausal symptoms, which have affected her mood and emotional well-being. She expressed feelings
of sadness and frustration but was able to communicate her emotions clearly. The patient has a high
school education and is able to read and write in English and Tagalog.

3. Environmental Status

The patient reported living in a concrete house with three bedrooms and two bathrooms, located in a
residential area. She described her neighborhood as quiet and safe. The patient reported that her home
is well-maintained, clean, and free from clutter. She also stated that she regularly cleans her home and
disposes of her garbage properly. The patient reported no concerns about her home environment
affecting her menopausal symptoms.

4. Sensory Status

a. Visual Status Patient:

The patient's conjunctiva appeared clear and white. She reported no visual disturbances or changes
related to her menopause.

b. Auditory Status

The patient's conjunctiva appeared clear and white. She reported no visual disturbances or changes
related to her menopause.

c. Olfactory Status

The patient reported no changes to her sense of smell related to her menopause

d. Gustatory Status

The patient reports a decrease in her sense of taste related to her menopause symptoms. She has no
difficulty in masticating or swallowing as verbalized. She has an intact gag reflex.

e. Tactile Status

The patient reported no changes to her sense of taste related to her menopause.

f. Language Perception and Formation

The patient is able to initiate and understand speech by giving queries on current health condition and
answering questions asked by the healthcare provider.

g. Sensory Environment

The patient is able to initiate and understand speech by giving queries on current health condition and
answering questions asked by the healthcare provider.

5. Motor Status

The patient is able to move all extremities without any difficulty. Muscle strength is normal on both
upper and lower extremities. No tremors or deformities noted on both upper and lower extremities.
Peripheral pulses were present such as radial. No crepitus noted upon flexion of joints. Extremities are
warm to the touch.
6. Nutritional Status

The patient's skin appears to be well hydrated with good skin turgor that returns in 1-2 seconds. Hair is
noted to be terminal in the scalp, eyelashes, and eyebrows with no parasite infestation. Lips and oral
mucosa are moist. The patient has a good appetite and consumes all the food served. The patient has a
medium body built. Patient sees foods as a source of energy and verbalized that she has no religious
restrictions about food as well as allergies. The patient has a high protein diet and low sodium diet, as
ordered by the physician. Bowel sounds are as follows: RUQ: 4, RLQ: 2. LUQ: 6; LLQ: 4, upon auscultation.
It reveals normal bowel sounds per minute. Abdomen is globular upon inspection and nontender in all
four quadrants upon palpation.

7. Elimination Status

The patient's frequency of urination is estimated to be 4-5 times per day at approximately 500 cc. She
uses the bathroom independently and privacy is observed. No pain was reported to be felt during
urination. Urinalysis revealed clear and light yellow urine. But there are difficulty defecating as the
patient said.

8. Fluid and Electrolyte Status

The patient is able to consume 1,500 cc of water. She is not hooked to any IV fluids. She has moist lips
and good skin turgor; skin and hair are well-hydrated. The patient's skin is light brown and has pinkish
nail beds. No signs of dehydration noted as well as edema formation.

9. Circulatory Status

The patient has a pulse rate of 72 beats per minute and a blood pressure of 120/80 mmHg while in a
sitting position. She has normal capillary refill of 1-2 seconds. She is not cyanotic.

10. Respiratory Status

She has a respiratory rate of 18 breaths per minute. No use of accessory muscles noted. Chest wall
symmetrically expands with each respiration and no retractions are seen.

11. Temperature Status

The patient verbalized feeling comfortable. Her temperature is 36.8OC, per axillary upon the initial vital
signs taking. The ward is adequately ventilated. The patient, as well, had used only one blanket, with
clothes made of cotton not greatly affecting the client’s temperature status.

12. Integumentary Status

The patient verbalized feeling comfortable. Her temperature is 36.8OC, per axillary upon the initial vital
signs taking. The ward is adequately ventilated. The patient, as well, had used only one blanket, with
clothes made of cotton not greatly affecting the client’s temperature status.

13. Comfort and Rest Status

The patient reported no sleep disturbance. But there is a lack of sleep caused by work.