VI. THIRTEEN AREAS OF ASSESSMENTI.

Psychological

Ms. D.B is a 27 year-old female and married. She lives with her parents and presently residing at #94
Happy Homes Baguio City. She is very dependent in terms of her health to her mother and other health
care professionals. The patient and her family is Roman Catholic and have no practices or beliefs which
might affect to providing health care. Watching the television, eating and singing is her way in spending
her leisure time. She has positive outlook with her life.

II. Mental and Emotional Status

The patient is conscious, alert and coherent. She is very responsive in verbal stimuli, noise, light, touch
and pain stimuli. She is oriented to current time, date and place. She acts according to her age. She has
good perception about her health. She is very cooperative and prevents somethings to further cause
damage to her health. The patient responded not that interested on the questions I asked. No social
concerns or fears were noted and no medicines or substances were taken to alter emotional response.
She verbalized that she is not stressed but very bored.

III. Environment Status

There are no sensory deficits and she is oriented that she is in the hospital. Patient is knowledgeable
about her conditions. There is steady pattern of activity, light noise and color in his environment and it
does not distract her. She is comfortable during sleep. The food and water or side table is placed at the
left side of the patient it is accessible for her needs. Patient is in the female surgical/ortho ward,
together with her mother.

IV. Sensory Status

There is no known visual deficit like color blindness. She can also distinguish voice evenfrom a distance,
loud or soft. No corrective auditory deficits. And no auditory device noted being used by the patient.
The patient is able to discriminate an odor from the other. The patientis able to discriminate sweet,
sour, salty and bitter tastes from each other. With regards to the patient’s tactile status, she was able to
determine that the patient is able to discriminate sharp anddull, light and firm touch, able to perceive
heat, cold, pain in proportion to stimulus, able todifferentiate common objects by touch by doing
necessary procedure. Patient has an intact bodyimage and there is no aberrant sensation.

V. Motor Status

Motor strength is assessed. Her movements are limited since she undergone an operation.The patient is
able to move and can move all her joints slowly and carefully as of the moment.. No prosthetic device
was noted present with the patient and all her extremities are intact. Sheverbalized that her mother can
assist her whenever she needs something.

VI. Nutritional Status

The patient food is being served in the hospital and she is in DAT. The patient appetite isgood. There is
no change in the appetite in eating during the hospitalization and health deviation.Teeth are complete
without dental carries. The skin is smooth and with brownish color. The nailswere fine and well
trimmed. There is no culture or religious dietary restriction reported by the patient. The patient is able
to swallow in her food and medications as well. The patient deniedany indigestion, vomiting. The patient
is eating orally by herself.

VII. Elimination Status

The patient eliminates in a toilet bowl once a day. The stool is usually brownish and semisolid. He drinks
water to aid her elimination. There is change in her out put. She verbalized thatshe frequently urinates
during her stay at the hospital. She urinated 1-2 times during my shift.She usually consumes 5-6 or more
glasses of water per day. The patient claimed absence of special problem like urinary and bowel
retention, urinary incontinence and diarrhea. Patientdenies feeling of thirst.

VIII. Fluid and Electrolyte Status

The patient usually drinks 5-6 glasses only of water daily and urinates regularly. She hasan ongoing IVF
of D5LRS x 1L regulated at 31 to 32 gtts/min. The patient denies the feeling of thirst. Her skin turgor is
normal and she has moist mouth and mucous membranes. The patient’scapillary refill is 1-2 seconds.

IX. Circulatory status

The pulse rate during the shift is 68 beats per minute which is in the normal range. The pulse was strong
with regular rhythm. With regards to emotional stress and physical activity, the pulse rate increases. The
patient’s blood pressure is 130/100. This was taken while the patient islying down in the bed.

X. Respiratory status

Her respiratory rate is 22 breaths per minute with no use of accessory muscles. There isno abnormal
breath sounds heard. The patient’s lip’s color is pinkish but slightly dry along withher nails.

XI, Temperature Status

Patient’s axillary temperatures is 36.5 C. There is no sign of profuse sweating or evenirritated. The
environmental temperature is cold and the humidity is high and the patient iscomfortable with it.

XII. Integumentary Status

Skin color is brownish and has a good skin turgor at 1- 2 secs. There are no wounds notedor reported by
the patient. The dressing is dry and intact and sometimes felt pain. Nails and hair are well kept by the
patient. There are no odorous secretions or oily secretions.

XIII. Comfort and Rest Status

The patient claims that normally she sleeps 8-10 hours in a day. Her sleep was now only6-7 hours during
hospitalization. She claims that she is very comfortable with her sleep even if she is in the ward but
sometimes being disturbed when nurses have to get her vital signs or givemedications.

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