Payangdo, Yza Grace S.

BSN 1-07

13 AREAS OF ASSESSMENT

1. Psychosocial Status
Mr. J is a 21 years old resident of Poblacion, Buguias, Benguet. Mr. J verbalized that he
currently provides his basic needs by working as a radio technician. His wife and relatives are
always around helping him in doing his activities of daily living. Patient is practicing Catholic.
Mr. J believes that his current condition is due to the effects of alcohol and believes that he
could overcome it.

2. Mental and Emotional Status

Mr. J 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. But during intake of Diazepam, the patient experience hallucination. He reported that
he sees things that others cannot see. He was able to finish college degree. He can read nor
write. He can understand English and Tagalog. As to his condition, he believes that his
condition is trial that could be overcome. Patient appears neat, wearing clean clothes. Nails
are tidy with no signs of keratinization. Hair is also well-groomed.

3. Environmental Status
Mr. J 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. Patient and family
members claim that they dispose their garbage properly. Alcohol was available at bedside for
disinfection. The patient is in medical extension ward. It is adequately ventilated. No
unnecessary noise was noted. It is also spacious and there are other patients. The floor was
also well maintained and non-slippery. No scatter rugs were seen. Other than that, patient has
no complaints of uneasiness or discomfort concerning his environment.

The home environment, as reported, is a concrete type of house with four rooms and
one comfort room. It is located near the road, thus, making his house expose to dust and
noise.
4. Sensory Status
a. Visual Status
 Mr. J has yellowish palpebral conjunctiva. He is able to move eyes without
tenderness, pain or difficulty.

b. Auditory Status Upon assessment

 No visible lumps or lesions noted, corrective devices used such as hearing aids
and discharges were noted.

c. Olfactory Status
 The patient has intact sense of smell as manifested by the ability to distinguish
familiar odor such as alcohol during assessment. No epistaxis was noted. Nose
was seen to be symmetrical, proportionate and no lesions seen.

d. Gustatory Status
 Mr. J is not using dentures. According to him, he has decrease sense of taste. He
has slight dry lips and oral mucosa. There is no difficulty in masticating and
swallowing as verbalized. He has intact gag reflex.

e. Tactile Status
 Facial sensations are also intact and symmetrical on both sides. He is able to
perceived heat, cold and pain sensations.

f. Language Perception and Formation

 Mr. J is able to initiate and understand speech by giving queries on current health
condition and answering questions asked by the student nurse.

g. Sensory Environment
 Environment is well ventilated. Ward is spacious and no unnecessary noises were
observed. Patient has no complaints of discomfort concerning his environment.

5. Motor Status
Mr. J 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.
Extremities are warm to touch.
6. Nutritional Status
Mr. J’s skin appears to be dry; he has a good skin turgor that returns in 1-2 seconds. Hair
is noted to be terminal in the scalp, eyelashes and eyebrows with no parasite infestation.
Patient has slightly dry lips and oral mucosa. The patient has poor appetite in eating; he
consumes 30% of food served. The patient has a medium body built. Patient sees foods as a
source of energy and verbalized that he has no religious restrictions about food as well as
allergies. The patient has a high protein diet and low sodium diet, as ordered by the physician.
Bowel sounds are as follows: RUQ: 4, RLQ: 2. LUQ: 6; LLQ: 4, upon auscultation. It reveals
normal bowel sounds per minute. Abdomen is globular upon inspection and nontender in all
four quadrants upon palpation.

7. Elimination Status
Mr. J’s frequency of urination is estimated to be 3 times per shift at approximately 750
cc. He uses the bathroom with assistance and privacy is observed. No pain was reported to be
felt during urination. Urinalysis revealed clear and dark yellow urine with a specific gravity of
1.030 is used as an indicator of the kidneys ability to excrete concentrated urine. As particle
increases, so does the specific gravity.

8. Fluid and Electrolyte Status

Mr. J is able to consume 350 cc of water. He is hooked to D5LRS 1L+ 2 amps. Vit. B
complex x 12 hrs, regulated at 83-84 gtts/min. He has dry lips. He has a good skin turgor; skin
and hair are slightly dry. Patient’s skin is brownish and has pinkish nail beds. No signs of
dehydration noted as well as edema formation.

9. Circulatory Status
Mr. J has pulse rate of 69 beats per minute and a blood pressure of 110/70 mmHg while
positions on semi fowlers. He has normal capillary refill of 1-2 seconds. He is not cyanotic. He
has a history of cigarette smoking and alcohol drinking.

10. Respiratory Status

Mr. J has a respiratory rate of 20 breaths per minute. No use of accessory muscles
noted. Chest wall symmetrically expands with each respiration and no retractions see. The
patient has history of cigarette smoking and alcohol drinking.

11. Temperature Status

Mr. J verbalized feeling of warmth and cold. His temperature is 37.6OC, 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

Mr. J’s skin is dry generally white, without pigmentations, no pallor, jaundice or
cyanosis. He has good skin turgor. 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.

13. Comfort and Rest Status

Mr. J sleeps experience sleep disturbance, as reported.