13 AREAS OF ASSESSMENT

1. Psychological/ Physiological Status

- Patient B is a man, 83 years old, who resides in a long-term care facility. He been
diagnosed with congestive heart failure, hypertension, arthritis, and hyperlipidemia
and has a history of two myocardial infarctions (eight and two years previously.
2. Mental and Emotional Status
- Patient B alert and oriented and answers questions appropriately. He is responsive to
verbal stimuli, noise, light, touch and pain. He is cooperative when performing any
diagnostic test.
3. Environmental Status
- Patient B is residing in a long-term care facility and was admitted to the emergency
room with good lighting, proper ventilation and a comfortable environment. Patient is
oriented that he is in the hospital.
4. Sensory Status
- There is no known visual deficit like color blindness. He can distinguish voice when
the one talking is near. Patient does not use any hearing aid and was able to hear
words without repeating it. Patient was able to discriminate sharp and dull and firm
touch, was able to perceived heat and cold. He was able to differentiate common
objects.
5. Motor Status
- Patient B is ambulatory and requires assistance with his activities of daily living.
Patient’s movement is limited because he gets tired easily due to his congested heart
failure.
6. Thermoregulatory
- Patient B was admitted to the emergency room with an initial temperature of 36.5.
His temperature ranges from 36.0-36.5 during the 3 days shift. Temperature is within
normal range. No sign of profuse sweating.
7. Respiratory Status
- Patient B was admitted to the emergency room with an initial respiratory rate of 22
breaths per minute. His respiratory rate ranges form 15-22 breath per minute during
the 3days shift. Respiratory rate during the first day of admission was higher than the
normal range with oxygen therapy. Second and third day of admission respiratory rate
was within normal range still with oxygen therapy.
8. Circulatory Status
- Patient B was admitted to the emergency room with an initial blood pressure of
112/62 mmHg and pulse rate of 92 beats per minute. BP and PR are within normal
range
9. Nutritional Status
 - Patient B’s height is 5ft and 9inch (175cm), weight is 63.kg with a normal BMI of
21.3. Patient appetite has been poor that causes him to lose weight. Patient is
dehydrated. Patient has dentures. Patient was able to swallow his food and
medication.
10. Elimination Status
- The patients eliminate in a bowl once a day. He frequently urinates during his stay at
the hospital. Patient denies the feeling of thirst.
11. Sleep, Rest and Comfort Status
- Patient B has been feeling chest pain that alter his comfort and sleep. Patient has been
sleeping 6-7 hours during hospitalization. He gets disturbed when nurses have to get
his vital signs or give medication.
12. Fluid and Electrolytes
- Patient usually consume 3-4 glasses of water a day. No ongoing IVF
13. Integumentary Status
- Patient B has a dry fair skin, which indicates dehydration. Skin turgor is 8-10
seconds. There are no wounds noted. No odorous secretion or oily secretion.