13 Areas of Assessment

I. SOCIAL STATUS
Findings:
Patient DML is a 59-year-old Filipina, currently living with her husband along with her
son at San Roque, Tarlac City. According to the patient, she is very active in their
neighborhood, and she always has time to visit her daughter’s family who lives 2 km
away from their home. She also mentioned that when she is in pain or having
problems, she is sharing them with her family. With the interview conducted patient
DML is very open with her family, she always shares her thoughts and feelings.
Norms:
Social status includes family relationships that state the patient’s support system in
times of stress and in times of need. It meets a fundamental need for social ties,
making life stressful, and social support buffers the negative effects of stress, thus
indicating indirectly contributing to good health outcomes (Kozier & Erb’s, 2018).
Analysis:
Patient DML’s social status was normal and does not affect her current condition.

II. MENTAL STATUS

Findings:
General appearance and behavior:
At the emergency room, the patient was well-groomed and dress appropriately. Upon
interview, the husband reported that he noticed that his wife was slurring her speech
and her face was drooping on one side. He also mentioned that his wife is
experiencing numbness on the right side of her face and down to the right arm.

Level of consciousness:
Patient DML is awake and alert with both eyes open and looking directly at the
examiner, she was able to state her name when asked, and the date and month
today.

Orientation:
The student nurse asked her some detailed questions about her name, age, date,
month, where she lives, and where she is. She was able to answer them correctly.
According to her, her name is DML, 59-year-old. The date today is December 3,
2021, she lived in San Roque, Tarlac City and she was admitted to Tarlac Provincial
Hospital.

Speech:
When we conducted the interview to test the patient's speech, the patient was asked
to state 10 countries, 10 fruits, and 10 colors. She was able to state them all clearly
and the student nurse noticed that she has a crooked smile with a slight facial
drooping on the right side and a minimal slurring of speech with a low modulated
voice.

Intellectual function:
The student nurse asked her to name all of her children and her husband. She was
able to respond to the questions properly and correctly. When the student nurse
asked if she can still remember her past history, she just nods her head as an
answer.
Norms:
General appearance and behavior:
The patient should be able to stand still, have smooth and coordinated movement
(Jensen, 2019).
Level of consciousness:
The patient must be alert and awake with eyes open and looking at the examiner and
able to respond appropriately (Kelley & weber, 2018).
Orientation:
A person is normally aware of self, others, place, time, and address (Weber, 2018).
Speech:
Speech should be at a clear and moderate pace. It should be exerted effortlessly
(Jensen, 2019).
Intellectual function:
A person should respond normally and appropriately to topics discussed. Express full
and free-flowing thoughts during the interview and listen and respond with full thought
(Jensen, 2019).
Analysis:
Patient DML’s general appearance was not normal because the student nurse noticed
that she has a crooked smile with a slight facial drooping on the right side and a
minimal slurring of speech.

III. EMOTIONAL STATUS

Findings:
The patient can voice out her own thoughts and feelings in detail despite experiencing
slurred speech. Her family felt saddened and nervous about her condition, but they
already learned to accept it. She also mentioned that this is the most stressful
situation in her life because it affects them financially and emotionally but she is
resilient and ready for whatever outcome.
Norms:
Normally, the patient should have the ability to manage stress and express emotion
appropriately. It also involves the ability to recognize, accept and express feelings and
to accept one’s limitations (Berman et.al., 2018)
Analysis:
Patient DML’s emotional status was normal and stable because her support system
did not leave her in her most difficult times. She managed to voice out her feelings
and thoughts sincerely on how grateful she was for having a family who was there for
her through thick and thin.

IV. SENSORY PERCEPTION

Findings:
a) Sense of Sight:
The patient's visual acuity was tested by asking her to stand 20 ft (6 meters) away
from the Snellen chart and she was asked to read the letters while covering her one
eye, she was instructed to begin reading the big letter until to the small letters. The
test was repeated to the opposite eye following the instruction. The patient was not
able to read due to blurry vision she also mentioned that whenever she is reading,
she’s using an eyeglass with a grade of +3.00.
The pupil reaction to light test was made to the patient, and the result was both of her
pupils are round, equal, and reactive to light (4 mm to 2mm), and accommodation.
There is no nystagmus noted.
b) Sense of Taste:
Lips were moist and pink in color. Both upper and lower teeth were slightly yellowish,
and a few cavities were noted. The tongue was pink in color, moist, and slightly
rough, and a tongue resistant test was performed, the patient was asked to push her
tongue against her left cheek as the student nurse apply resistance the test was
repeated to the other side as well, and it was proven that the patient has difficulty in
pushing her tongue to the right side. Gag reflex was tested and assessed as
functioning well. To test the patient's sense of taste, the patient was asked to
distinguish between sweet, sour, salty, and bitter tastes (Macaroon, Kamias, table
salt, and bitter melon) respectively from each other still being blindfolded. The patient
was able to distinguish them correctly.

c) Sense of Hearing:
Auditory acuity to whispered or spoken voice was assessed to the patient, including a
watch tick test. Cerumen was visible in the ear canal of both ears. The result was,
patient, is unable to hear properly to the watch tick test and the word whispered by
the student nurse. The tympanic membrane was pearly grey in color.

d) Sense of Smell:
No signs of a lesion, swelling, or flaring on the nasal septum. The nose is uniform in
color. Sinuses were palpated and no evidence of swelling or lumps was noted, and
no pain was felt by the patient either. Patient DML was given two cups being
blindfolded, she was instructed to smell on each cup. The first cup contains coffee
while the second cup contains cinnamon bread. She was asked to identify both
substances. The patient was able to identify which is which.

e) Sense of Touch, Pressure & Pain

With regards to the patient’s tactile status, she was asked to close her eyes and the
student nurse will touch her with wisp cotton on her forehead, cheek, and jaw on each
side, then followed by the test pain perception, the student nurse used the tip of the
hairpin to touch the same 3 areas. And she was asked to compare both sensations.
The patient stated that“ yung ginawa mo kanina sa kanan na bahagi ng muka ko
naramdaman ko na malambot yung una mong tinusok saakin tapos yung pangalawa
masakit kapag nadiin ang tusok” she also added that “ pero sa kaliwang bahagi ng
muka ko wala akong naramdaman nung tinusok mo ko, parang namamanhid kasi
yung kaliwang bahagi ng muka ko hanggang sa kamay” A hard object was placed in
her lower extremities and a light object too in her upper extremities and she was able
to distinguish the weights applied to her extremities. During the assessment, the
patient added that “medyo mabigat yung nasa baba tapos magaan naman yung nasa
taas”
Norms:
a) Sense of Sight:
Vision occurs when light is processed by the eye and interpreted by the brain. Light
passes through the transparent eye surface (the cornea). The pupil, the black opening
in the front of the eye, is an opening to the eye interior. It can get larger or smaller to
regulate the amount of light entering the eye. The colored portion, called the iris, is a
muscle controlling the pupil size. The inside of the eye is filled with a gel-like fluid.
There is a flexible, transparent lens that focuses light, so it hits on the back of the eye
(the retina). The retina converts light energy into a nerve impulse that is carried to the
brain and then interpreted no nystagmus was noted
b) Sense of Taste:
Taste is intact in the posterior one-third of the tongue. (Health Assessment and
Physical Examination, Mary Ellen Zator Estes)
c) Sense of Hearing:
For the auditory acuity, the client should be able to repeat the whispered words from
two feet. (Health Assessment and Physical Examination, Mary Ellen Zator Estes)
d) Sense of Smell:
Your sense of smell helps you enjoy life. You may delight in the aromas of your
favorite foods or the fragrance of flowers. Your sense of smell is also a warning
system, alerting you to danger signals such as a gas leak, spoiled food, or a fire. Any
loss in your sense of smell can harm your quality of life. It can also be a sign of more
serious health problems.
e) Sense of Touch, Pressure & Pain
The skin contains receptors for pain, touch, pressure, and temperature. Sensory
signals are transmitted along rapid sensory pathways, and less distinct signals such
as the pressure of localized touch are sent via slower sensory pathways. (Health
Assessment and Physical Examination, Mary Ellen Zator Estes)
Analysis:
a) Sense of Sight:
Patient DMLM’s blurring vision was due to her aging process.
b) Sense of Taste:
Patient DML’s tongue strength was not normal she has difficulty in pushing her
tongue on her right side of the face, however, her sense of taste was normal.
c) Sense of Hearing:
Patient DML has difficulty hearing due to her aging process.
d) Sense of Smell:
Patient DML’s sense of smell can perceive stimuli accordingly which was considered
normal.
e) Sense of Touch, Pressure & Pain
Patient DML’s sensory transmission was proven not functioning well she can’t feel
anything on the right side of her body due to numbness.

V. MOTOR STABILITY
Findings:
During the assessment, patient DML show’s willingness to cooperate she was able to
move in command and was able to understand the instruction being said. When the
patient was asked to stand from the chair and walk a straight line, she was able to
walk with a stable gait. While she was walking the student nurse, noticed that the
patient’s posture is slightly asymmetrical her right shoulder is slightly low compared to
her left shoulder. The student nurse asked her to lift both arms and was proven that
she cannot lift her arms evenly. Wrist and fingers were tested, the patient was asked
to spread her fingers and resist as the student nurse attempted to push the fingers
together to both hands. The patient was able to spread her fingers on her left arm but
had difficulty with her right arm. Lastly, Grip strength was also tested, the patient was
asked to grasp the student nurse’s index and middle fingers while she will try to pull
her fingers out. The patient was able to grip the fingers properly using her left hand
while the right hand was not able to grasp the fingers.
Norms:
The normal range is that the patient has a good posture, easy walks, transfers from
bed to chair, and walks fast not just slowly. In standing position, the torso and head
are upright. The head is midline and perpendicular to the horizontal line of the
shoulder and the pelvis. The shoulders and hips are levels, symmetry of the scapula
and iliac crests. The arms are free from the shoulders. The feet are aligned, and the
toes point forward. Walking initiated in one smooth rhythmic fashion (Jensen, 2019).
Analysis:
Upon the assessment, patient DML muscle strength on her right arm is weaker than
her left arm due to her condition, especially because of the numbness on her right
arm.

VI. BODY TEMPERATURE

Findings:
The table below shows the temperature of the patient during the shift:
DATE ASSESSED TIME ASSESSED TEMPERATURE ANALYSIS
December 3, 2021 8 am 36.7 °C Within the normal
range
December 3, 2021 12 pm 37.2 °C Within the normal
range
 December 3, 2021 4 pm 36.9 °C Within the normal
range
Norms:
Normal axillary temperature is within 36.4 to 37.4 centigrade (Berman et.al., 2018)
Analysis:
Patient DML’s body temperature was normal
Drugs

DOSAGE,
ROUTE and MECHANISM OF CONTRAINDICATIO NURSING
NAME OF DRUG INDICATION SIDE EFFECTS
FREQUENC ACTION N RESPONSIBILITIES
Y
Generic name: 50 mg/12.5 Losartan and its Losartan Hypersensitivity to CNS: dizziness, Before:
LOSARTAN WITH mg tab PO principal active Potassium/ thiazides, vertigo,  Assess for BP
 Inform patient
HYDROCHLOROTHIAZIDE OD in am metabolite block the Hydrochlorothiazide sulfonamides; fluid or paresthesia’s,
regarding drug
vasoconstrictor and is indicated for the electrolyte imbalance weakness, purpose and the
aldosterone- treatment of and to renal or liver headache, need to comply with
medications.
Brand name: secreting effects of essential disease. drowsiness,
During:
Hyzaar angiotensin II by hypertension in fatigue  Check for rashes
selectively blocking patients whose CV: orthostatic and temperature
elevation daily
Classification: the binding of blood pressure is hypotension,
 Monitor patient for
Combination of an ACE angiotensin II to the not adequately venous manifestation of
inhibitor and a diuretic. AT1 receptor found controlled on thrombosis, hypomagnesemia,
in many tissues, losartan or volume hyponatremia, and
hypokalemia
(e.g., vascular hydrochlorothiazide depletion, After:
smooth muscle, alone. cardiac  Instruct patient to
adrenal gland). arrhythmias, report any adverse
reaction.
chest pain
 Monitor BP closely to
Hydrochlorothiazide GI: nausea, evaluate
inhibits reabsorption vomiting, effectiveness of
 of sodium and anorexia, dry therapy.
chloride in distal mouth, diarrhea,
renal tubule, constipation,
increasing excretion jaundice,
of sodium, chloride hepatitis,
and water by the pancreatitis
kidney. DERM:
photosensitivity,
rash, hives,
purpura

OTHERS:
muscle spasm,
cramps, fever,
gouty attacks,
hyperglycemia

NAME OF DOSAGE, MECHANISM OF INDICATION CONTRAINDICATIO SIDE EFFECTS NURSING

 ROUTE and
DRUG FREQUENC ACTION N RESPONSIBILITIES
Y
Generic name: 750 mg 1 tab It decreases Metformin is used Contraindication CNS: Headache, Before:
METFORMIN PO hepatic glucose with a proper diet includes dizziness, agitation,  Check glucose level before
giving metformin.
BID production, and exercise hypersensitivity, fatigue.
 Check for drug
Brand name: decreases intestinal program and chronic heart failure, Metabolic: Lactic compatibility because
Glucophage absorption of possible with other metabolic acidosis acidosis. many drugs interact with
oral hypoglycemic
glucose, and medications to with or without coma, GI: Nausea, vomiting,
reactions
Classification: improves insulin control high blood diabetic ketoacidosis abdominal pain, bitter During:
Biguanides insensitivity by sugar (DKA), severe renal or metallic taste,  Observe for s&s of
hypoglycemic reactions.
increasing disease, abnormal diarrhea, bloatedness,
 Metformin should be taken
peripheral glucose -It is used in creatinine clearance anorexia; malabsorptio with food
uptake and patients with type resulting from shock, n of amino acids, After:
utilization. 2 diabetes septicemia, or vitamin B12, and folic  Report significant changes
to the physician.
myocardial infarction acid possible.  Monitor and teach patient
-It controls the and lactation. for signs of hypoglycemic
blood sugar to help reactions, advise to take
sugar containing drinks or
prevent kidney
hard candy when
damage. hypoglycemic reaction
begins if patients become
unconscious, administer
20-50 ml of D50 water
(50% glucose solution)
over 2-3 mins or inject
glucagon (1mg SQ/ IM)