VI. THIRTEEN AREAS OF ASSESSMENT

I. 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 some things 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 even from 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 patient is 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 and dull, light and firm touch, able to perceive heat, cold, pain in proportion to stimulus, able to differentiate common objects by touch by doing necessary procedure. Patient has an intact body image 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. She verbalized 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 is good. 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 nails were 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 denied any 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 semi solid. He drinks water to aid her elimination. There is change in her out put. She verbalized that she 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. Patient denies feeling of thirst.

VIII. Fluid and Electrolyte Status

The patient usually drinks 5-6 glasses only of water daily and urinates regularly. She has an 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’s capillary 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 is lying down in the bed.

X. Respiratory status

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

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

XII. Integumentary Status

Skin color is brownish and has a good skin turgor at 1- 2 secs. There are no wounds noted or 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 only 6-7 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 give medications.