13 Areas of Assessment

1. Psychological Status
Mr. Y is a 46years old, from Ampucao Itogon. He is currently residing there with his family.
Patient is optimistic regarding his condition and is looking forward to get better anytime soon. He
is dependent in terms of health to his wife and other health care professionals. He is a Roman
Catholic and have no practice or beliefs which might affect to providing health care.

2. Mental and emotional Status

Patient is conscious, responsive, and active. The client is a 46year old laborer. He is responsive in
verbal stimuli, noise, light, touch and pain stimuli. He acts according his age. He is cooperative in
terms of taking vitals signs. No social concerns or fears were noted and no medicines were taken
to alter emotional response.

3. Environmental Status
Patient Y’s bedside were located at MO 7-4, the room were occupied with 4 patients including
patient Y. The room were spacious with one common bathroom/cr. Six big windows were present
which resulted for good ventilation. Patient was admitted at the medical ward with good
lightning. Foods were provided by the hospital.

4. Sensory status
Patients visual, Auditory, olfactory, gustatory, tactile status and Gustatory are functioning well as
evidenced with no presence of visual deficit, no corrective auditory deficit and no auditory
device, no presence of nasal flaring, he is able to discriminate sweet, sour and salty and able to
perceive heat, cold and pain.

5. Motor Status
He is active, his movements are limited, he can walk, sit and stand with the help of the Nurses or
his family. He is able to move all his joints and can grasp or grab anything he likes.
6. Nutritional status
The Patient’s food is being served in the hospital and sometimes her wife and other relatives
bring in food whenever they visit. He has a good appetite but he is picky of his foods, he eats a lot
and take his medication properly.
7. Elimination status
The patient eliminates in a toilet bowl once a day. The stool is usually brownish and semi-solid.
He drinks a lot of water as verbalized. During my shift the patient’s elimination status is:
Date Time Urine Stool
November 14,2022 3pm-11pm 4 1

8. Fluid and Electrolyte

Patient was in PNSS 1L x KVO infusing well at right hand. Able to drink properly and can drink
200cc during the shift.

9. Circulatory status
Date Time Blood Pressure SPO2
November 14, 2022 3pm-11pm 157/79 98%
Data shows the Vital sign of the patient, where blood pressure was taken in the brachial artery
with normal result of 157/79 during the first taking of Vital sign.

10. Respiratory
Date Time Respiratory Rate SPO2
November 14, 2022 6:00 pm 17 98%
A respiratory of 17 and with a 98% of SPO2 taken at the left index finger of the client. No visible
of disproportionate chest, and the pattern of inhalation were normal and no unnecessary sounds
were noted during the first taking of vital signs.

11. Temperature
Date Time Temperature
November 14, 2022 6:00 pm 37.1
Patients temperature were normal during the first taking of vital signs in the afternoon.

12. Integumentary
During the assessment, hair of the client is well distributed with black. Color of the skin is fair
with his nails properly groomed. There is no presence of wounds, ulcer, and pressure sores. Upon
assessment patient have less of doing personal hygiene with odor and excretions (oily,
perspiration).

13. Comfort and Rest Status

Prior to Hospitalization patient could sleep well but with agonizing pain of his back with 3-4
hours of sleep every night. Mr. Y stated that he felt comfortable when laying down but
uncomfortable in sitting position as verbalized.