3.

13 AREAS OF ASSESSMENT
I. Psychological Status
The patient is an Ilocano. She stays in their house at 63 Blk 1 West Quirino Hill Baguio
City with her siblings and mother. Their family belongs to the middle class socio-economic
group because her father is an OFW at Dubai and she has 4 siblings. The patient is the 3 rd child.
They are Lutherans and say that they do not have beliefs that would affect their health. Upon
admission, patient was in a semi-private room but was transferred to the reverse isolation room.
She is 11 years old, a grade 6 pupil, and is under the school age stage of development with a
central task of industry by Erik Erikson. She is developing sense of competence and
perseverance.

II. Mental and Emotional Status

Patient is alert and awake and responds immediately when asked questions. She is very
much oriented to time, place and to people around her. She responds to verbal stimuli – she is
able to answer to questions appropriately; for example she is able to state her condition prior to
her admission. She responds to noise and light. Her score in the Glasgow coma scale is 15 (4 –
eyes open spontaneously, 5 – oriented, 6 – obeys verbal command.) She thinks just appropriate
for her age. At present, she is a grade 6 pupil, able to read and write and able to comprehend and
follow instructions. She has a short attention but long memory span. The patient stated that she
has fever that’s why she was admitted in the hospital. The patient is presently diagnosed with
Dengue Fever but is already not manifesting fever upon the assessment and visit. Ultrasound
revealed abdominopelvic ascitis, Reactive cholecystitis, and Pleural Effusion. This was her first
time of hospitalization. She believes that she will get well very soon. At present the patient is not
irritable and still thinks positively because of the support of her family. She has a good and open
communication with her family and peers.

III. Environmental Status

Patient is 11 years old and is able to tolerate ambulation but only within a short distance
because she admits that she feels dizzy at times. The patient has limited movements in moving
from side to side, from supine to sitting or sitting to supine, repositioning self in bed, moving
from supine to prone or prone to supine. She is experiencing abdominal pain specifically at the
right upper quadrant and right flank area which is aggravated by sudden movements. She needs
assistance in moving around. At present, patient stays at the reverse isolation room in order to
protect her from any infection. Health care workers wear mask when entering the room. The
room is adequately lighted and ventilated. The room has enough space. No one in the family has
an infectious disease at the moment and no visitors are allowed inside the room. She is oriented
to the environment. The patient does not use any prosthetic or supportive devices to move
around.

IV. Sensory Status

VISUAL STATUS: The eyelids of the patient are proportionate with skin. Eyes are
normally symmetrical with the face and in level with each other. Eyelashes and eyebrows are
equally distributed. No tenderness noted on his eyelids. Palpebral conjunctiva is pinkish. She
does not wear eyeglasses/ contact lenses. She has normal vision as assessed upon admission.
Pupils are equally round, reactive to light and accommodation.
AUDITORY STATUS: Ears of the patient are proportionate with the head and face. The
two pinna are bilaterally symmetrical and in level with the lateral canthus of the eyes. Moreover,
during palpation, no lumps or lesions are noted. Her ear canals are clean for there is absence of
discharges and cerumen noted. She is able to distinguish voices of her family. There are no
known deficits noted
 OLFACTORY STATUS: The patient’s nose has the same color with face. It is also
proportionate with the head and face. There are no lesions or deviations noted. Upon inspection
and palpation, no occlusions or tenderness noted. Her nasal cavity is pinkish in color. There is an
absence of inflammations, swelling, exudates or abnormal discharges. She is able to discriminate
odors.
GUSTATORY STATUS: The patient is able to discriminate sweet, sour, salty and bitter.
She has no unusual sensations like lack of taste and the like.
TACTILE STATUS: The patient is able to discriminate sharp and dull, light and firm
touch. In addition to this, she is able to perceive heat, cold and pain in proportion to stimulus.
She can discriminate common object by touch such as pillows and coins and denies any aberrant
sensations.
SPEECH FORMULATIONS AND PERCEPTIONS: Speech organs of the patient are
intact. There are no deficits in phonation noted. She is able to understand and initiate speech. The
lips of the patient are symmetrical. It is pinkish in color and it was indicated that she has moist
lips with no presence of lumps or ulcers.

V. Motor Status
The patient has limited physical movements at the moment due to her abdominal pain.
Muscle strength is 5/5 in all extremities. The patient is right-handed. There are no deformities
noted. She is able to perform full range of motion on all extremities. She does not have any
supportive aids when walking. Patient has no muscular abnormalities like paralysis. She cannot
do vigorous activities at the moment due to her condition.

VI. Nutritional Status

The patient eats about 5 times a day and eats 1 cup of rice, vegetables, and meat
particularly in equal proportions. Her mother is the one responsible for preparing their foods. She
stated that she loves to eat chocolates and does not eat junkfoods. During snacks she usually eats
fruits, bread, or chocolates. Patient admits that she has poor appetite. She does not take in any
nutritional supplements such as vitamins .She is currently 130 cm in height with a weight of 36.1
kg and has medium body built. In their religion, they do not have religious restrictions when it
comes to food. Patient has dental carries. She admits that she only does oral care once a day. She
is able to swallow properly. He has no allergies to food. Upon admission, she was under DAT
and was advised to avoid dark-colored foods. At present, she is already on Full diet. Patient is
currently on 8) D5LRS x 27 gtts/minute. She was also administered 6 FFP. 2 days ago, she stated
that she had episodes of vomiting characterized as previously ingested foods but at present, there
was none.

VII. Elimination Status

As verbalized, she does not defecate daily but there was no problem when it comes to
urination. She characterized her stool as brownish in color and semi-formed. Black-tarry stool as
evidence of bleeding is not noted. Her urine is yellowish in color amounting approximately 200
cc per void. She states that she usually urinates 3-4 times a day. The patient further claims that
there is no associated painful sensation upon defecation and urination. She can control her
urination and does not have any incontinence.

VIII. Fluid and Electrolyte Status

The patient has a current weight of 36.1 kilograms. Patient is currently on 8) D5LRS x 27
gtts/minute and had received 6 FFP transfusions. She has a good skin turgor which returns after
1-2 seconds. She has moist mucous membranes. She is awake and alert. She drinks about 3-4
glasses of water daily prior to condition. Diagnostics revealed abdominopelvic ascitis, Reactive
cholecystitis, and Pleural Effusion. Patient was diagnosed of Dengue Fever. Her abdomen is
distended and has 76 cm abdominal girth. Change in the size of abdomen was noted during the
hospitalization. Upon percussion, abdomen has dull sounds. Normoactive bowel sounds were
noted upon auscultation. No pain is felt upon palpation.

IX. Circulatory Status

Upon assessment, patient has a pulse rate of 64 beats per minute, +2 on the radial pulse
and is regular. Concerning the pathophysiology of her condition, it is necessary to take her blood
pressure. Patient’s blood pressure was 100/70 taken in a sitting position. The patient is acyanotic.
Nail beds are pinkish without clubbing and has a capillary refill of 1 – 2 seconds. No noted
palpitation, orthopnea and chest pain. No evidence of bleeding episodes was noted. Patient had
received 6 FFP transfusions. Diagnostic results also showed decreased thrombocytes (108). This
means that clotting time may be decreased. Prothrombin Time Activity was also tested which
resulted to 11 seconds (Ref. value: 9.8-12.7 sec) and still in the normal range.

X. Temperature Status
The patient is able to perceive heat and cold. When the patient feels cold, she requests
additional clothes and puts on her blanket but when she feels warm, she requests that extra
clothings be removed or uses clothes with thin fabrics. Body temperature upon assessment was
36.1C, axillary. Environmental temperature is cool. At present, she was prescribed with
Paracetamol 250 mg/5 mL 7.5 mL q4 RTC. Positive Dengue DOT NS1 resulted last July 13.

XI. Integumentary Status

The color of her skin is brownish, smooth in integrity. No noted lesions. The patient has
no decreased or increased pigmentation. Skin is easily lifted and returns in 1 – 2 seconds. Nail
beds are firm, pinkish with no evidence of clubbing or spooning and forms about 160 degrees.
She has capillary refill of 1-2 seconds. Her hair is black in color, oily with no balding, lengthy
and with no dandruff or any evidence of pediculosis. Eyebrows and eyelashes are evenly
distributed and black in color. The palpebral conjunctiva is not pale and the bulbar and the sclera
are whitish. The eyelids have the same color with the face and have no scaling and drying. The
pinnas of the ears are in lined with the lateral canthus of the eye. The lips are not pale or dry with
no scaling and evident lumps, lesions, or ulcers. Her teeth have dental caries. The tongue is
located midline, and generally pinkish. The buccal mucosa is pinkish and with no inflammation.
There is no area of erythema present. Patient stated that she takes a bath every other day.

XII. Comfort and Rest Status

She usually sleeps at 9PM and wakes up at 6AM. Her sleeping pattern is not easily
interrupted. At present, she is experiencing abdominal pain specifically at the right upper
quadrant and right flank area which is aggravated by sudden movements. No pain is noted upon
plapation. Upon assessment, patient rated the pain as 5 out of 10 having 10 as the highest though
there are times that it is 7. She considers watching TV, listening to music, and reading books as
her form of relaxations at home.

XII. Respiratory Status

Upon assessment, patient has a respiratory rate of 26 cpm and is regular. Diagnostic
results showed that she has Pleural Effusion. There were no retractions and no use of accessory
noted. Symmetrical chest expansion was also noted. Patient stated that she has difficulty of
breathing sometimes. Upon auscultation, decreased breath sounds are heard at the right lung.
The patient also has occasional dry cough. No supportive devices regarding respiration is noted.