Marquez, Crystal Queen

13 AREAS OF ASSESSMENT
 
1. PSYCHOLOGICAL
A 43-year-old male was referred by the Community Quarantine Facility to
the hospital for admission due to intermittent fever, latest body temperature
per axilla is 39.5 0C. Five days prior to admission had developed a flu like
symptoms. He has a history of exposure to a confirmed COVID 19 patients. His
NPS/OPS result came out to be positive for SARS-CoC-2. The patient is a
known hypertensive, diabetic and asthmatic patient but no recent history of
hospitalization or surgeries.
2. MENTAL AND EMOTIONAL STATUS
Patient was seen awake and not in any signs of cardiopulmonary distress. He is conversant, coherent and
responds appropriately to verbal and non-verbal stimuli. He is well oriented to time, place and person. He
is able to initiate limited activity and is able to show response to pain stimuli. During the interview, he is
able to express his feelings and uses clear words.

3. ENVIRONMENTAL STATUS
Patient is well oriented to the environment and is familiar with the room set-up. He has intravenous
access on his right arm for his IV fluids that may potentially expose her to infection and lines may limit
her general mobility. Bed rails are available. The home environment, as reported, is a concrete type of
house with four rooms an done comfort room. It is located near the road, thus, making his house expose
to dust and noise
4. SENSORY STATUS -
There is no known visual deficit like color blindness. He 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, he 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.

5. MOTOR STATUS 
Motor strength is assessed. His movements are limited. Patient is on sitting position with slightly
limited movement. He has muscle strength of 3/5 on both upper and lower extremities, which
means that he has limited movement against gravity and some resistance. Further, no tremors and
deformities noted on both upper and lower extremities. Upper extremities are symmetrical as well as the
lower extremities. Peripheral pulses were present such as radial. No crepitus noted upon flexion of joints.
6. NUTRITIONAL STATUS
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 pallor. 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.
 Marquez, Crystal Queen

7. 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 output. he verbalized that he frequently urinates during
her stay at the hospital. he urinated 1-2 times during my shift. he 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

8. FLUID AND ELECTROLYTE STATUS 

The patient usually drinks 5-6 glasses only of water daily and urinates regularly. 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. 

9. CIRCULATORY STATUS
The pulse rate during the shift is 89 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 140/90 which indicate hypertension. This was taken
while the patient is lying down in the bed 

10. RESPIRATORY STATUS  

His respiratory rate is 24 breaths per minute with no use of accessory muscles. There are no abnormal
breath sounds heard. The patient’s lip’s color is pinkish but slightly dry along with her nails. 

11. TEMPERATURE STATUS  

Patient’s axillary temperatures is 38.5 C., per axillary upon the initial vital signs taking. The
ward is adequately ventilated. The patient, as well, had used only one blanket, with clothes made of
cotton not greatly affecting the client’s temperature status
12. INTEGUMENTARY STATUS
His nail base is soft when palpated, with capillary refill of 1-2 seconds. His hairs are dry, evenly
distributed, no parasite infestations, and well-trimmed. His hair is thin, fine and gray. His conjunctiva is
slightly pale, sclera is white in color. There are no wounds noted by the client. Nails and hair are well
kept.

13. COMFORT AND REST STATUS

he claims that normally he sleeps 8-10 hours in a day. And claim that he’s comfortable. he claims that he
is very comfortable with his sleep even if she is in the ward but sometimes being disturbed when nurses
have to get her vital signs or give medication.