13 Areas of Assessment

I. Psychosocial and Psychological Status

As claimed by the patient’s husband, she does not not attend social gatherings as much. She
has few friends from the church, but she prefers bonding with her relatives. A good point is
that the patient manifested a strong relationship with her husband. She consulted him in her
decision to undergo the surgery. She understands what causes her pain and the need to
perform a surgery to remove her gallbladder. She asks if there are other options other than
surgery, however it was explained to her that it was the best option in her case. She willingly
follows the order of not not eating and drinking prior to her surgery.

II. Mental and Emotional Status

Before the surgery, the patient verbalized “I am scared to be operated”, manifesting her fear
of the upcoming operation. She was quiet most of the time, but cooperative when we assisted
her to change into her hospital gown and do a skin test. After the surgery, she was
unconscious when transferred to her room and was asleep for at least an hour. After two
hours, the patient appears lethargic, and almost crying because of the pain, and cold due to the
wearing off of the anesthesia. She was aware that she was back in her room, and she was still
able to communicate her needs as she requested for additional blankets.

III. Environmental Status

The patient was admitted in the pedia ward as there were no available beds in the surgery and
medical ward, so she shared the room with one patient. Her room is spacious and is near the
nurses’ station. It is well ventilated, a comfort room is available inside, and bedrails are pulled
up. In addition, there is lighting and good water access. Drinking water and food are located
on her bedside table. She has no complaints of discomfort or uneasiness in the environment.

IV. Sensory Status

a. Visual Status
Through observation, the patient does not have visual deficits; she is not using any
correctional glasses. Also, with the use of penlight, pupils are noted to be equally round and
reactive to light and accommodation. She is able to move her eyes smoothly without reporting
tenderness, pain or difficulty during the assessment of cranial nerves III, IV, and VI.

b. Auditory Status
Patient’s ears are symmetrical, no drainage or impacted cerumen noted during assessment.
The patient is not using any auditory devices (hearing aids) and she can clearly hear the
questions being asked as there is no need for repetition of the questions.

c. Olfactory Status
Patient has an intact sense of smell as she complained “I do not like the smell in the hospital”.
Nose is symmetrical, proportionate and no lesions were seen.

d. Gustatory Status
She can differentiate sour, sweet, salty and bitter tastes. No reported problems with
masticating and swallowing when the patient had her chicken soup. An intact gag reflex was
noted when the patient was complaining about the hospital smell.

e. Tactile Status
Patient has no tactile problems; she complained of pain when she was in the operating room
saying she could feel that she was being cut, and she felt very cold and was shivering after her
surgery.

V. Motor Status
Motor strength was assessed by pulling the patient’s extremities and asking the patient to pull
on the opposite side. The patient’s motor strength is 3/5 on the upper extremity and 2/5 on the
lower extremity. Patient is lying flat on bed just after her operation, movement is limited due
to the IV line on her R hand. She is experiencing mild pain and seems lethargic after surgery.

VI. Thermoregulatory Status

The patient verbalized feeling cold and was shivering after her surgery and asked for extra
blankets, though her temperature was 36.5℃ per temporal artery upon vital sign taking.

VII. Respiratory Status

The chest shape of patient J is normal and symmetrical movement with inhalation. When the
patient breathes in, the chest expansion is normal however there is an occasional use of
accessory muscles after the surgery.

VIII. Circulatory Status

No abnormal heart sounds upon auscultation. The table below shows the heart rate and blood
pressure taken during the time of duty.

IX. Nutritional Status

The patient was on NPO upon admission as preparation for her surgery. After the operation,
she was on a clear liquid diet followed by a diet as tolerated (DAT) as ordered. After 11pm on
February 14, 2022 as per doctor’s order, she was 12 allowed to eat and drink a small amount
since it’s her first post-op meal. She was able to finish a bowl of chicken soup. Patient has a
normal body mass index with a result of 19.3, with a weight of 45 kg and a height of 5ft.

X. Elimination Status
Patient didn’t urinate and defecate after surgery at the time of the shift. Although on the
following day, her urine output was recorded at 850 ml and urinated 4 times during the day
shift and was able to defecate once; she mentioned she had just a small amount of loose
brown stool. No catheter noted after the surgery.

XI. Sleep, Rest and Comfort Status

Patient has no definite time of sleeping before and after her surgery. Her minimum sleep
hours after her surgery was only about four hours because of the continuous vital signs
monitoring and also because of the pain on the incision site. Discomfort is also observed as
her movements are limited especially when she tries to turn on her side. On the following day
after her surgery, the patient appeared more rested, and she claimed was able to sleep for
longer hours and can go to the comfort room with minimal assistance.

XII. Fluids and Electrolytes Status

The patient reported that she usually drinks 5-6 glasses of water daily when at home, however
she was ordered to be on NPO before her surgery and clear liquid diet after her surgery. No
signs of dehydration or edema formation noted. She has an ongoing IVF of PLRS 1Lx41-42
gtts/min at 900cc level on her right hand; To follow with an IVF of PLRS 1Lx12 hours.

XIII. Integumentary Status

The patient has smooth skin with good turgor, nails are spoon shaped and has a good capillary
refill. The wound has a clean dressing upon assessment that is
dry and intact. No lesions, pallor, redness and swelling present on the face and both
extremities. She has a tan complexion, she is properly groomed and hair is evenly distributed.
She has a black colored hair and no presence of parasite infestation observed.