13 AREAS OF ASSESSMENT

1. PSYCHOSOCIAL AND PSYCHOLOGICAL STATUS

Mr. Z is 3 years old, born on April 11, 2016. He lives with his parents and is currently residing at
100 Purok 2, Gibraltar, Baguio City. He is dependent in terms of his health to her mother and
other health care professionals. He and his family is a Roman catholic and have no practices or
beliefs which might affect to providing health care.

2. MENTAL AND EMOTIONAL STATUS

Mr. Z is conscious and active. He is responsive in verbal stimuli, noise light, touch and pain
stimuli. He acts according to his age. He is cooperative in terms of taking vital signs. No social
concerns or fears were noted and no medicines were taken to alter emotional response.

3. ENVIRONMENTAL STATUS
Patient was admitted at the pediatric ward with good lighting, congested due to many
patients, with student nurses, staff nurses and doctors consistently monitoring them, ward is noisy
because it is overpopulated that even the hallways were occupied just like Mr. Z’s bed. Even
with all the noises, the patient was able to sleep as long as his mother is with him.

4. SENSOR STATUS
a. Visual Status
There is no known visual deficit like color blindness.
b. Auditory
No corrective auditory deficits and no auditory device noted being used by the
patient. He can also distinguish voices.
c. Olfactory Status
There is no presence of nasal flaring. The patient is able to distinguish an odor.
d. Gustatory Status
He is able to discriminate sweet, sour, salty and bitter taste from each other.
e. Tactile Status
He is able to perceive heat, cold, pain with regards to stimulus, able to differentiate
common object by touch and able to discriminate light and firm touch.

5. MOTOR STATUS
He is active, his movements are not limited, he can walk, sit, and stand by himself. He is
able to move all his joints and can grasp or grab anything he wants.

6. THERMOREGULATORY STATUS
Date Time Temperature
4pm 37.2 °C
October 28, 2019 8pm 36.8 °C
10pm 36.7 °C

7. RESPIRATORY STATUS
Date Time RR SPO2
4pm 29 cpm 93 %
October 28, 2019 8pm 29 cpm 93 %
10pm 28 cpm 98 %
8. CIRCULATORY STATUS
Date Time CR
4pm 112 bpm
October 28, 2019 8pm 114 bpm
10pm 115 bpm

9. NUTRITIONAL STATUS
The patient’s food is being served in the hospital and sometimes her mother and other
relatives bring in foods whenever they visit. He has a good appetite but he is picky of his foods,
if he likes the food then he eats a lot but if not her mother has to persuade him to eat just a little
so that he can take his medications.

10. ELIMINATION STATUS

The patient eliminates in a toilet bowl once a day. The stool is usually brownish and semi-
solid. He drinks a lot of water as verbalized by mother. During my shift the patient’s elimination
status is:
Date Time Urine Stool

October 28, 2019 3pm – 8pm 2 1

11. SLEEP, REST AND COMFORT STATUS

Patient can rest and sleep as long as his mother is with him but sometimes being disturbed
by loud noises and when I take the vital signs and during time of giving medication. Mother
verbalize that the patient wants his mother to be with him during sleep even at home.

12. FLUIDS AND ELECTROLYTES STATUS

The patient has no IVF, with heplock. The patient drinks a lot of water as verbalized by
mother. His skin turgor is normal and he has moist mouth and mucus membranes. The patient’s
capillary refill is 1-2 seconds.

13. INTEGUMENTARY STATUS

Skin color is brownish and has a good skin turgor at 1-2 seconds. There are no wounds
noted or reported by the patient or his mother. Nails and hair are well kept by the patient’s
mother.