13 AREAS OF ASSESSMENT

I. Patient's Profile

1. Personal Data

Mr . X is a 78 years old who is a widowed.

Admiting Diagnosis - Abdominal pain

He was brought in the hospital due to abdominal pain

Final Diagnosis is Pancreatic Mass

II. 13 Areas of Assessment

1. Psychosocial and Psychological Status

Mr X is a 79 year-old widowed. He is a husband with 5 children. He is not dependent in terms of her

health to health care professionals. The patient is an Esperitista while his family are Roman Catholic and
he have practices or beliefs which might affect to providing health care. Farming is his way of spending
his leisure time and he has positive outlook with his life.

Erickson's Psychosocial Theory

- Based on Erickson's psychosocial theory, Mr. X on his Ego integrity versus despair is the eighth and final
stage of Erik Erikson's stage theory of psychosocial development. This stage begins at approximately age
65 and ends at death. It is during this time that we contemplate our accomplishments and can develop
integrity if we see ourselves as leading a successful life.

Mental and Emotional Status

-The patient is conscious but anxious about his condition, He is responsive in verbal stimuli, noise, light,
touch and pain stimuli. He is oriented to current time, date and place. He manifests grimaces upon initial
assessment and he verbalized that he is afraid to die. However, He still acts according to his age and
cooperate to prevents some things to further cause damage to his health.

3. Environmental Status

There are no sensory deficits and he is oricnted that he is in the hospital. Patient is afraid about his
conditions but there is steady pattern of activity, light noise and color in his environment which quite
distract him.bThe food and water or side table is placed at the right side

of the patient and is accessible for his needs. The patient is on soft diet and ordered with bulos feeding
with Ensure. Patient is in the Surgical Ward together with his one grand children.
4. Sensor Status

a. Visual Status

In assessing the vision, patient is instructed to look straight to observe the general appearance his eyes.
Eyes are almond in shape, irises are black in color, scleras are whitish in color, and eyebrows and
eyelashes are equally distributed. Patient is also instructed to follow the direction of a finger with her
eyes following six cardinal gazes, and her eyes were able to move in full rangc of motion and in all
directions. There is no known visual deficit like color blindness. The patient does not use eyeglasses or
contact lenses.

b. Auditory

General appearance of Mr. X were parallel, symetrically proportional to the size of the head and bean
shaped, firm cartilage and with a presence of cerumen. He can also distinguish voice from a distance,
loud, or soft. No corrective auditory deficits. And the is also no auditory device noted being used by the
patient.

C. Olfactory

Patients nose has no deviation in terms of shape and size. No discharges were seen during assessment,
and no history of sinus infection. He can also identify scented object even with close eyes . And no
abnormalities noted.

D. Gustatory Status

Mr. X's lips were symmetrical in shape but bluish in color during assessment. There are present of tooth
decay. No dentures and no signs of gingivitis.

E. Tactile Status

He was able to distinguish sharp and dull, light and firm touch. Hee is also able to perceive heat, cold,
pain in proportion to stimulus. He was asked to close his eyes, a cotton ball was stroke to the back of his
neck, then using another cotton ball, alcohol was poured on it and rubbed it on thc same area, and he
stated that he felt a sensation of wet and cold on her skin. Using the case of BP apparatus which is rough
in textur and the pencil which is smooth in texture, the paticnt is asked to touch the two materials and
ask the texture while blindfolded. After thc test, she corrcetly identified the difference of two materials.

5. Motor Status

Motor strength is assessed. His movements are limited. Since he experiencing abdominal pain and back
pain. No prosthetic device was noted present with the patient and all his extremities are intact. He
verbalized that his children assist him whenever he needs something.
6. Thermoregulatory Status

Mrs. X is febrile. There is a sign of profuse sweating. However, the room is ventilated which helps with
the condition of the patient.

Date Time Temperature

October 31, 2022 7pm 36.6

November 1, 2022 7pm 36

November 2, 2022 7pm 36.7

7. RESPIRATORY STATUS

His rhythm and respiration are regular. And has effective breathing pattern .Lungs were auscultated for
adventitious sounds and noted crackles on both based of his lungs.

Date Time RR

October 31, 2022 7pm 22

November 1, 2022 7pm 24

November 2, 2022 7pm 20

8. CIRCULATORY STATUS

The pulse rate during the initial assessment is around 90 which is normal. Cardiac ausculation reveals a
rapid regular rhythm and a murmur . His blood pressure is also high which is because of his HPN and is
experiencing abdominal pain in relation to pancreatic mass. However, with immediate treatment, her BP
went down together with his pulse rate at the end of the shift.

9. NUTRITIONAL STATUS

The patient is being feed every 4 hours with soft diet and Bulos feeding with Ensure. During the
assessment she verbalized that she defecated frequent times daily with black watery stools. He is also
on JP drain with 550 cc every shift. His urine is usually yellowish in color. She usually consumes sips of
water as ordered.
11. SLEEP, REST , AND COMFORT STATUS

The patient claims that normally he sleeps around 6hoirs in a daily. His sleep now was only 4-5 hours
during hospitalization. He claims he is uncomfortable with his sleep in the ward and sometimes being
disturbed when nurses get his VS and give medications. She also complains of flank pain which he rated
as 8/10 on the pain scale of 1 being the lowest and 10 being the worst possible pain. He was given
Tramadol for his flank pain an dwas seen comfortably sleeping at the end of the shift.

12. FLUIDS AND ELECTOLYTE STATUS

The patient usually sips water only as ordered. And denies the feeling of thirst and his capillary refill is 3
seconds.

13. INTEGUMENTARY STATUS

Skin color is pale in appearance. However, there are no wounds/skin lesions noted or reported by the
patient. Nails and hair were well kept by the patient and no history of skin allergy