13 AREAS OF ASSESSMENT

I. Psychosocial Status

Patient LP is 1 month old male born on September 24, 2016. Patient LP is currently residing in
Tayug, Pangasinan living together with his extended family . He is the first child in his family. He is a
Filipino and his religion Roman Catholic. According to Erik Erikson Psychosocial Theory, he is in the stage
of infancy under Trust vs. Mistrust ages 0-18 months, the mother have been seen caring for patient LP
by attending to his needs like changing the diaper, breastfeeding and changing his clothes this means
that he is totally dependent on other for his needs. Success on this stage means that the patient will
develop a sense of trust, if this fail it will lead to Mistrust.

Based on Sigmund Freud Psychosexual Theory, patient LP is under the Oral stage. During the oral
stage, the patient LP’s primary source occurs through the mouth, so rooting and sucking reflex is very
important. The mouth is vital for eating and it derives pleasure from oral stimulation through gratifying
activities such as tasting and sucking.

II. Mental and Emotional Status

Patient L.P is conscious, cries whenever he’s hungry. According to Jean Piaget Cognitive
Development theory under Sensorimotor of development that in stage 1 it is through birth until 1
month of birth, infants exclusively use their reflexes such as sucking and rooting , and their cognitive
capabilities are only limited. He only communicates when he cries.

III. Environmental status

Patient LP lives in their own house in Tayug together with his mother , grandparents, and his
father who is a smoker. The mother said that their house is a Bungalow type with 2 rooms with a
separate kitchen and she said that they live near the road. Prior to hospitalization the patient stays at
home. During the hospitalization, the patient was admitted at the Pediatric Ward 2nd floor in a ward that
held 14 beds. Good lighting, not well ventilated consisting one window and was a little congested, but
the patient’s mother reported that they were comfortable because they developed a bond with the
other patient’s significant others.

IV. Sensory Status

Vision: He is reactive to light, conjunctiva is pale, the sclera is yellowish in color and no
presence of discharges noted.
Hearing : Respond to crying of the other patient’s babies by means of waking up
immediately on his deep sleep after hearing it.
Smell: There is no presence of nasal flaring.
Taste: Good sense of taste as proven by good sucking reflex.
Tactile: The patient responds to pain whenever the nurse administers medication in his
heparin IV lock.
 V. Motor status

Patient L.P. was able to grasp when putting the fingers in his hands, while his feet can flexed
and extend.

VI. Nutritional Status

The patient is purely breastfed. Prior to hospitalization the patients weight is 3 kg. during
course of hospitalization his weight increased to .2 which is already 3.2 in kg.

VII. Elimination Status

Prior to hospitalization, patient LP’s mother stated that she changes the diaper 2-3
times per day that contains urine only and sometimes urine and feccal that is yellowish in color
with soft consistency. She also mentioned that there are times where the diapers are fully
soaked.

VIII. Fluid and Electrolytes Status

The source of patient’s fluid is breast milk. We received the patient with an ongoing
intravenous fluid of 250cc regulated for 24 hours D5 0.3 NaCI in his right arm.

IX. Circulatory Status

The cardiac rate of patient L.P ranges from 130-151 beats per minute. During the rotation no
abnormal cardiac rate noted. The normal cardiac rate of a 1 month infant is 90-150bpm.

October 31, 2016 Cardiac Rate

3pm 130bpm NORMAL
6pm 135bpm NORMAL
10pm 135bpm NORMAL
November 1, 2016
3pm 150bpm NORMAL
6pm 144bpm NORMAL
10pm 140bpm NORMAL
November 2, 2016
3pm 136bpm NORMAL
6pm 151bpm NORMAL
10pm 147bpm NORMAL

X. Respiratory Status
 The table below shows the patient’s respiratory rate ranging from 31-39 cycles per minute are
all in normal as 25-40 cycles is the normal. The oxygen saturation ranges from 91%-98% where two is
detected below normal 94% and 91% the normal value for oxygen saturation is 95%-100%.

October 31, 2016 Oxygen

Respiratory saturation
Rate
3pm 34cpm NORMAL 94% BELOW NORMAL
6pm 32cpm NORMAL 97% NORMAL
10pm 36cpm NORMAL 97% NORMAL
November 1, 2016
3pm 38cpm NORMAL 97% NORMAL
6pm 37cpm NORMAL 98% NORMAL
10pm 39cpm NORMAL 95% NORMAL
November 2, 2016
3pm 36cpm NORMAL 91% NORMAL
6pm 32cpm NORMAL 96% NORMAL
10pm 31cpm NORMAL 96% NORMAL

XI. Temperature Status

During the rotation patient LP is afebrile. No sign of profuse sweating noted.

October 31, 2016 Temperature

3pm 36.7 NORMAL
6pm 36.4 NORMAL
10pm 36.9 NORMAL
November 1, 2016
3pm 36.7 NORMAL
6pm 36.8 NORMAL
10pm 36.5 NORMAL
November 2, 2016
3pm 36.5 NORMAL
6pm 36.0 NORMAL
10pm 36.2 NORMAL

XII. Integumentary Status

The skin is slightly dry and yellowish in color no presence of lesions and rashes observed.
With slow skin turgor.

XIII. Rest and Sleep Pattern

Prior to hospitalization the mother said that patient LP sleeps for most of the time, but cries
when he feels hungry. During hospitalization he sleeps after being breastfed, he easily woke
up whenever he hears noises.