Orpilla, Allysa Megan D.

BSN 3B-A

Patient Diagnosis: CVD acute Infarct right Paramedianpontine artery territory probably
small branch occlusion in etiology NIHSS 9 Hypertension stage 2 uncontrolled

13 AREAS OF ASSESSMENT

I. Physiological and psychological status

Patient X is a 54 year old male, married and a resident of Pozorrubio,

Pangasinan. The patient and his family are Roman Catholic and have no practices or
beliefs which might affect providing health care. He also has a good relationship with his
family and also very sociable with other people.

II. Mental and Emotional Status

He is conscious and coherent. He speaks, Tagalog, Ilokano and English

language. He is cooperative and able to recall recent and remote memories. The patient
is well oriented in place, time and person. During the interview the patient was able to
express his feelings and concerns about the complications.

III. Environmental Status

He is admitted to the Neuro ward of Baguio General Hospital. His bed was
located at the left side of the ward close to the nurse’s station. The patient is provided
with pillows and a blanket. The bedside table is organized with only necessary things
and his medication. The area was provided with adequate lightning but not well
ventilated.

IV. Sensory Status

A. Visual Status

He was able to open his eyes independently, move them without tenderness,
without pain or difficulty. Moreover, he is able to follow the six fields of gaze and can
distinguish color.

B. Auditory Status

Using the whisper test, the patient has equal perception on his right and left ear
by being able to respond and comprehend the words whispered to him. There are no
visible lumps or no lesions noted, no corrective device used such as hearing aids. No
discharges were noted.

C. Olfactory Status

The patient has no nasal discharge and no tenderness upon palpation. He is able
to respond to any aroma provided such as orange fruit and bathroom soap.

D. Gustatory Status

The patient is not using dentures. He is on NGT feeding.

E. Tactile Status

The patient was able to perceive heat, cold and pain sensations and he is able to
distinguish dull and sharp.
V. Motor Status

The patient needs full assistance and support when assuming self-care needs.
No tremors and deformities noted on both upper and lower extremities. Moreover, he is
able to initiate limited range of motion on his right side of his body.

VI. Thermoregulatory Status

Date Time Temperature Remarks

December 20, 2023 12 am 36.8°C Normal
1 am 37.8°C Above Normal
2 am 37.9°C Above Normal
3 am 37.9°C Above Normal
4 am 37.2°C Normal
5 am 36.5°C Normal
6 am 36.5°C Normal

December 21, 2023 12 am 36.5°C Normal

1 am 36. 7°C Normal
2 am 37. 1°C Normal
3 am 36.7°C Normal
4 am 36.5°C Normal
5 am 37. 2°C Normal
6 am 36.5°C Normal
Analysis: The patient has a fever on December 20 at 1am to 3am, where his
temperature reached 37.9°C. The patient was given paracetamol to relieve fever.

VII. Respiratory Status

Date Time RR SPO2

December 20, 2023 12 am 24 bpm 97%
1 am 23 bpm 97%
2 am 22 bpm 95%
3 am 22 bpm 97%
4 am 21 bpm 96%
5 am 23 bpm 97%
6 am 22 bpm 97%
December 21, 2023 12 am 22 bpm 96%
1am 24 bpm 98%
2 am 23 bpm 97%
3 am 22 bpm 97%
4 am 23 bpm 95%
5 am 21 bpm 96%
6 am 23 bpm 96%
Analysis: His respiratory rate was 21-24 bpm throughout the shift (normal range: 12-20
bpm) with no abnormal breath sounds heard. His SPO2 ranges from 95- 98% (normal
range: 95%-100%). The result is a manifestation of effective breathing pattern.

VIII. Circulatory Status

Date Time CR BP
December 20, 2023 12 am 80 cpm 150/90 mmHg
1 am 76cpm 130/80 mmHg
2 am 75cpm 140/80 mmHg
3 am 78cpm 140/80 mmHg
4 am 70cpm 130/80 mmHg
5 am 71cpm 130/80 mmHg
6am 70cpm 130/80 mmHg
December 21, 2023 12am 75 cpm 140/80 mmHg
1am 79 cpm 140/90 mmHg
2am 80 cpm 150/ 80 mmHg
3am 75 cpm 130/80 mmHg
4am 72 cpm 130/90 mmHg
5am 70 cpm 130/80 mmHg
6am 75 cpm 130/80 mmHg
Analysis: Patient’s cardiac rate ranges from 70-80 cpm (normal range: 60-100 cpm) and
blood pressure of 130/80 – 150/90 mmHg throughout the shift (normal range: 120/80
mmHg). This was taken while patient is lying in the bed.

IX. Nutritional Status

The patient is being fed through NGT with feeding. He has warm and dry skin.
Abdomen is flat upon inspection and non-tender upon palpation. The appetite is not
assessed due to the patient’s condition.

X. Elimination Status

The patient’s urinary frequency is monitored every shift at approximately 1,200

ml. He is in a catheter. The intake is usually 2000mL and the output is 2220 during the
shift. The patient’s urine is yellowish in color. Moreover, she is in diaper and defecated
twice during the 3 days of duty.

XI. Sleep, Rest and Comfort Status

The patient is in O2 inhalation via nasal cannula. Physicians also ordered to keep
the head of the bed 30 degrees or higher. Clients with NG tubes are at risk for
aspiration, especially if they are receiving enteral nutrition.

XII. Fluids and Electrolyte Status

The patient is hooked on PNSS 1L x 8 hours regulated at 41-42gtts/min. The

feedings through NGT were also added in patient’s consumption. \

XIII. Integumentary Status

The patient’s skin is fair in color, skin feels warm, with no discolorations and has
normal skin turgor. Hair is finely distributed in the scalp, eyelashes, and eyebrows with
no parasite infestation. Nails are smooth, firm, clean, and no presence of clubbing.
Capillary refill within 1-2 seconds.