13 Areas of Assessment

1. Psychosocial and Psychological Status

According to Erik Ericson’s stages of Psychosocial Development, the patient falls under identity
vs. rule confusion. Patient Leni is a 12 years old female, a Roman Catholic and born on June 19,
2009 at Lutheran Abatan, Buguias, Benguet. They are currently living at Bangao, Buguias,
Benguet with her parents. His family belongs to the middle class and all her medical expenses are
being supported by his parents. She is not used to socialize with other people and his family
accepts any medical practices and do not adhere to so called “faith healing”.

2. Mental and Emotional Status

Client is conscious, alert, coherent, oriented and conversant. She is a 12 years old female and
currently studying. Patient’s chronological age is directly proportional to his developmental age
and acts according to her age. He appears to be neat and wearing a clean gown. During the
assessment, she is well-oriented to time, place, and person, and able to do limited ADLs. she is
able to respond appropriate verbally and maintain eye to eye contact. The patient is very thankful
with his parents because they always support her.

3. Environmental Status

In Buguias, Benguet, she currently lives in a semi-concrete house with 5 rooms. The patient states
she is only staying in her room and is not going out. She shares her room with her older sister.
The room has 3 large windows which resulted in good ventilation. Their house is in a spacious
area with lots of trees. They have their water being delivered and their toilet facility is a water-
carriage type. They also have easy access in areas like supermarkets, job hubs, malls and
hospitals as their apartment is located near such areas. While in hospital, patient Leni is admitted
and placed in pediatric ward with quiet environment, and adequate lighting, and air ventilation.

4. Sensory Status

a. Visual Status

The patient has 20/20 vision by doing Snellen chart test and 20 feet away from the chart. The
peripheral vision of the client is normal nothing seen during the assessment. Eyes are almond in shape,
irises are black in color, sclera is white, eyebrows and eyelashes are evenly distributed. Her conjunctiva is
moist and pinkish. Her eyes can follow the six cardinal positions and eyes were able to move in full range
of motion in all directions.

b. Auditory

The patient can distinguish voices whether they are near or far. No corrective auditory deficits and
no auditory device noted being used by the patient. Patient was also able to repeat the whispered words on
both ears when the whisper test was conducted. He verbalized that she has no known auditory deficits nor
ear infection history and unusual sensations like ringing or buzzing.

c. Olfactory Status
 Nose has no deviation in terms of shape and size. No discharges were seen during the assessment.
Orange peel and apple peel were used for this test and the patient was able to differentiate both smells
from each other signifying that there are no obstructions or abnormalities.

d. Gustatory Status

Her lips are dark in color and dry but symmetrical in shape. Tongue is darkish in color and there is
a presence of tooth cavities. For this test, the patient was asked to taste a pinch of salt and sugar with his
eyes closed and he was able to correctly identify both samples.

e. Tactile Status

Patient was asked to close his eyes and a cotton ball was used to stroke on his neck, then, using
another cotton ball, the student nurse poured alcohol on it and rubbed it on the same area and he stated
that he felt a wet and cold sensation on his skin. We also randomly introduced the sharp and dull ends of a
fork and he was able to distinguish the sharp and dull ends. She is also able to differentiate common
objects by touch such as coins and papers by doing necessary procedures. Patient has an intact body
image.

4. Motor Status

Her movements are limited and she needs assistance and support when assuming self-care needs
because of difficulty in breathing. Patient can only move in limited positions because of difficulty of
breathing. Patient verbalized, “medyo maul-ulaw ak bas-sit ya medyo hanak maka anges”.

6. Thermoregulatory Status
Date Time Temperature
7am 39.1 °C
November 5,2021 3pm 37 °C
11pm 37.9 °C
7am 38.3 °C
November 6, 2021 3pm 37.5 °C
11pm 37.9 °C
7am 38.5 °C
November 7 ,2021 3pm 37.4 °C
11pm 38 °C

7. Respiratory Status
Date Time RR SPO2
7am 22 cpm 88 %
November 5 ,2021 3pm 19cpm 90 %
11pm 15 cpm 89 %
7am 20 cpm 90 %
November 6, 2021 3pm 19 cpm 92 %
11pm 18 cpm 89 %
 7am 18 cpm 93 %
November 7 ,2021 3pm 18 cpm 95 %
11pm 17 cpm 94%

There were a presence of adventitious breath sounds upon auscultation.

8. Circulatory Status
Date Time CR Capillary
November 5 ,2021 7am 105 bpm
3pm 99 bpm 2-3 seconds
11pm 95 bpm
November 6 ,2021 7am 96 bpm
3pm 100 bpm 2-3 seconds
11pm 94 bpm
7am 113 bpm
November 7 ,2021 3pm 98 bpm 2-3 seconds
11pm 95 bpm

9. Nutritional Status

Prior to hospitalization, the patient stated “mahilig ak mangan ti ice cream ken white meat ken mahiligak
ag inom ti ice cold water ken juice”. Patient also mentioned that she has no known food allergies. When it
comes to eating, she needs assistance. Patient was also advised to increase oral intake like foods that are
rich in protein such as nuts and sardines, as well as increase water intake to 3 liters a day, or drink tea and
Gatorade for hydration.

10. Elimination Status

Patient stated that she urinate 3 to 4 times a day. His urine was yellowish in color and voided
about 300 to 400 mL per urination. Passing bowel open problem-free and no excessive bleeding.

11. Sleep, Rest and Comfort Status

Prior to hospitalization, patient stated that she rest and sleeps about 6-8 hours a day. She
verbalized “medyo hanak makaturog tani marigrigatanak maka anges”. During assessment, she stated she
was not able to sleep well at night due to the usual rounds and taking of vital signs of the health
practitioners. On the 2nd and 3rd day PTA, she stated that she was able to take some rest as she was able
to breath properly. Drinking warm water or tea and taking prescribed medication helped decrease chest
pain, sore throat and excessive cough, as verbalized by the patient. SHe also practices the use of deep
breathing to properly breathe but facial grimacing while moving was still observed.

12. Fluids and Electrolytes Status

 Patient stated before she was not diagnosed with pneumonia, she was drinking water, about 6
glasses of water per day and since the weather in Buguias is hot, she stated he drinks ice cold water and
juice as a way to cool herself down from the heat.

In the hospital, patient stated that she is drinking water. sHe verbalized, “Ag in inumak met ti
danum no mariknak nga nasakit manen jay lalamunak””. sHe drinks about 6 glasses of water per day.

13. Integumentary Status

During assessment, she has a good skin turgor, no history of skin allergy, bed sore or skin lesions.
sHe is dark in complexion, Skin was warm to touch. The patient verbalized hygiene practices like taking a
bath every other day and brushing teeth three times a day. she wears a fairly neat gown and nails are
trimmed short. Her hair is black, thick and long, presence of minimal dandruff was not seen.