C.

DEVELOPMENTAL DATA
A. In Erik Erikson Developmental Stage, he states that at the age 40-65
years old it is Generativity and stagnation where it is middle adulthood
wherein according to Erikson adults need to create or nurture things that will
outlast them, often by having children or creating a positive change that benefits other
people. Success leads to feelings of usefulness and accomplishment, while failure results in
shallow involvement in the world. Patient X is in the category of middle adulthood
since she is at 40-65 years old.
Positive Resolution: building a family, have a successful career.
Negative Resolution: unproductive and stagnant.
The patient achieve trust and mistrust as evidenced that the mother is
caring for him and he feel love. And also the child feels safe and
secure.
B. For Havighurst Developmental Task
Developmental Tasks of Middle Age
1.Achieving adult civic and social responsibility
2. Establishing and maintaining an economic standard of living
3. Assisting teenage children to become responsible and happy adults
4. Developing adult leisure-time activities
5. Relating oneself to one’s spouse as a person
6. Accepting and adjusting to the physiologic changes or middle age
7. Adjusting to aging parents.

13 AREAS OF ASSESSMENT
1. Psychosocial Status
Patient maintained balance with a minimal assistance
2. Mental and Emotional status
Patient is conscious, alert and coherent. She is very responsive in verbal, light touch and pain
stimuli. Patient is oriented to current time, date and place.
3. Environmental Status
The patient lives in an apartment
4. Sensory Status
a. Sight:
b. Smell: The patient pinches her nose while drinking tomato juice.
c. Taste: Patient show sour face after she drink with the tomato juice
d. Touch:
e. Hearing: Patient looked back when called, smiled and accept assistance when offered.
5. Motor Status
 Upon assessing the patient, she is able to fix her blanket with minimal assistance. Patient also is able to
sit from supine position without assistance.

6. Nutritional Status
Patient X is 45 kgs. Which is not appropriate to a pregnant woman. Upon hospitalization the
patient is able to drink fluids (water, and juice). And she was able to consume 80% of food
served. Patient is in DAT diet (Diet as Tolerated).

March 2, 2021
8AM Water 460
Juice 115
10AM Water 230
12 NN Water 460
2PM Water 115
Tomato Juice 115
Total 1495
March 3, 2021
8AM Water 460
Juice 230
10AM Water 115
12NN Water 460
2PM Water 115
Mango Juice 230
Total 1610

7. Elimination Status
Urine

March 2, 2021
8AM 100cc
10AM 150cc
2PM 300cc
Total 550cc
March 3, 2021
8AM 200cc
10 AM 300cc
2PM 100cc
Total 600cc

Stool- On March 3 she only had once at 2pm in the afternoon.

8. Fluid and Electrolyte Imbalance

INTRAVENOUS FLUID FORM

No. of Type of Volume and Date and Date and Time How many
bottle fluid duration Time consumed / ml?
Started Discontinued
Revised
1 D5IMB 1L x 24 hours March March 3, 2021 1000ml
2,2021
2 D5IMB 1L x 24 hours March 3, March 4, 2021 1000ml
2021
Total 2000ml

9. Circulatory Status

Date Time Pulse rate Spo2

March 2, 2021 8AM 82bpm 96%
10AM 88bpm 95%
12NN 83bpm 98%
2PM 87bpm 96%

March 3,2021 8AM 88bpm 95%

10AM 83bpm 96%
12NN 83bpm 98%
2PM 85bpm 96%

The patient pulse rate and Spo2 from march 2-3 ,2021 are within normal range. Based from
the assessment the patient lowest PR is 82bpm and the highest is 87bpm which normally
ranges to 60-100bpm.
And for the Spo2, the lowest spo2 is 95% and the highest is 98 % which normally ranges to
95%-100% for adults.

10. Respiratory rate

DATE TIME RESPIRATION RATE

March 2, 2021 8AM 22bpm
10AM 20bpm
12NN 24bpm
2PM 23bpm
March 3,2021 8AM 25bpm
10AM 24bpm
 12NN 20bpm
2PM 20bpm
The patient respiratory rate from March 2-3,2021 are higher than the respiration rate of 16-
20bpm. The patient lowest RR is 20bpm and the highest is 25bpm. But base from the assessment the
patient doesn’t have difficulty of breathing.

11. Temperature Status

Date Time Body Temperature

March 2,2021 8AM 36.6
10AM 36.0
12NN 36.3
2PM 36.2
March 3, 2021 8AM 36.2
10AM 36.2
12NN 36.5
2PM 36.8
The patient had an episode of hypothermia during my 2 days shift especially on 8am -2pm
on March 2, 2021 and 8am and 10am on March 3, 2021. But on 12nn and 2pm the body
temperature returns to normal.
12. Integumentary Status
The patient has a messy hair and visible flakes when she received the medications I
observed that her nails are short but with dark stain around and under the finger nails.
13. Rest, sleep, and comfort status
The patient was able to take a nap after the interview without being bothered with the
noise inside the hospital.