13 Areas of Assessment

a. Social Status

He is a 49-year-old male from Tarlac City, Tarlac, Philippines. He lives with his wife and

3 daughters who are all generally healthy. They live in a bungalow house with electricity and

water supply. Their house is 20 meters away from neighborhood and has 2 stray pets (1 dog and

1 cat). The patient is the breadwinner and currently works as a carpenter. He is very involved

with his family and attends Catholic services weekly. His family is generally healthy.

Norms: The ability to interact successfully with people and within environment of which each
person is a part, to develop and maintain intimacy with significant others and to develop respect
and tolerance for those with different opinion and beliefs are necessary determinant for a
person’s social state. The ability to achieve balance between work and leisure time is also a
needed factor. A person’s belief about education, employment and home influence personal
satisfaction and relationship with others (Kozier and Erb’s 2015)

Analysis: The patient has a good relationship with his family and friends.

b. Mental Status

b.1 Level of Consciousness:

He is alert, awake, and were able to open his eyes spontaneously. He was able to answer all the
questions given to him correctly and he can also obey commands, but his responses are in a slow
manner because he inability to fully open his mouth. Patient Glasgow coma scale was normal.
Patient Glasgow coma scale

Behavior Response Interpretation

Eye opening response 4 Spontaneous eye response
Verbal Response 5 Speaks coherently
Motor Response 5 Obeys in command

Norms: Patient should be able to correctly respond to questions and should be able to evaluate
and act appropriately in situations requiring judgment. (Estes, 2014)

Analysis: He is alert, responds readily and appropriately to all commands. but his responses are
in a slow manner because he inability to fully open his mouth. Glasgow coma scale was normal.

b.2 General Appearance and Behavior:

The patient is well-groomed and presentable despite his condition. He was dressed
simply and his hair and nails are trimmed and clean. He patient looks anxious and sweaty and
during interview he revealed extended stiff neck and partially opened mouth (locked jaw).

Norms: Patient’s movement should appear relaxed. The facial expression should be appropriate
to the content of the conversation and should be symmetrical. The appropriateness and degree of
affect should vary with the topics and the patient’s cultural norms, and be reasonable or
(normal). (Estes, 2014)

Analysis: He is well-groomed and well-oriented. He appears uncomfortable due to his condition

and associated symptoms.

b.3 Orientation:

While conducting the interview, he was able to provide all pertinent data such as his full
name, age, where he was at that moment and the date/day, month, and year. Generally, he was
able to answer and understand all the questions given to him during the assessment.
Norms: A person is commonly aware about self, others, the place, date, and time and address.
(Weber, 2013)

Analysis: The Patient is oriented to person, place, date, and year. He was able to understand the
questions and the conversation.

b.4 Speech

During the interview, the patient was able to formulate his thoughts although he was
speaking slowly most of the time. But he was able to verbalize his concerns.

Norms: Speech should be clear and moderate pace. It should be exerted effortlessly. (Estes,
2014)

Analysis: The patient speaks slow because according to the patient he experiencing difficulty in
opening his mouth fully and dysphagia persisted but he was able to say what are his concerns .

b.5 Intellectual Functioning

During the initial assessment, he was able to respond to the questions properly and
correctly. He was able to remember past events and recent happenings.

Norms: A person should respond normally and appropriately to topics discussed. Express full
and free-flowing thought during the interview and listen and responds with full thought (Estes,
2014)

Analysis: The patient was able to recall previous events and has normal intellectual functioning.

c. Emotional Status
 According to the patient he is very worried about his condition and what will happen to him.
He obviously looked anxious due to his condition. He worried about the needs of his family
because he is a breadwinner but then Mr. FM and his family worked together to help each other
despite his condition.

Norms: Normally, the patient should have the ability to manage stress and to express emotion
appropriately. It also involves the ability to recognize, accept and express feelings and to accept
one’s limitations (Berman, 2018)

Analysis: Patient tries to manage his condition by staying calm during assessment, anxiety was
evident. He could verbally speak his condition and was able to accept his condition.

d. Sensory Perception

d.1 Sense of sight

His eyebrows and eyelids when closed are symmetrically aligned. Both eye colors are
dark brown; sclera is white with pink conjunctiva. He does not wear any corrective lenses and
with the Use of a Snellen’s chart the patient can clearly see with a 20/20 vision. Cardinal gaze
was also performed, and the patient was able to move his eyes on all sides without difficulty. His
pupil was equally rounded and was able to dilate and constrict when penlight was passed on both
eyes. Visual field test is performed using a penlight and he can see it on his peripheral vision. To
test the visual acuity words and phrases from a book was asked for the patient to read that is held
20 inches away. He has no difficulty reading the words and phrases.

Norms: The client who has a visual acuity of 20/20 is considered to have normal visual acuity.
The eyes must be symmetrical during the six cardinal gaze’s test. The sclera shod be white with
some small blood vessels. Papillary constriction should occur when struck by light. (Jensen,
2019)

Analysis: Normal findings

d.2 Sense of smell

His nose is symmetrical, and both of his nostrils are patent and free of lesions. The
patient was asked to identify two common odors while his eyes are closed using an alcohol and a
perfume. He accurately identified the two substances when they were passed under his nose.

Norms: Nose must be symmetrical and along of the face. Each nostril must be patent and
recognize the smell of an object (Jensen, 2019)
Analysis: Normal findings

d.3 Sense of hearing

His ears are both clean, firm, non-tender, symmetrical in appearance, and has no
discoloration were noted. He does not have any complaint of ear pain.

Using the whisper test, to assess if he has a good sense of hearing with the distance of 2
feet away from the patient, he was able to determine and repeat the words correctly in both ears.

Norms: Patient should be able to repeat the words whispered from the distance of 2 feet. (Estes,
2014)

Analysis: Normal findings

d.4 Sense of taste

The Patient’s teeth complete, the tongue is on midline position with no muscle twitching.
His Uvula and Tonsils are both intact with no inflammation noted. To assess if he has a good
sense of taste, we ask him to describe the taste of the last food he ate. Using a tongue depressor,
the patient’s gag reflex was tested and but inability to move it correctly because his mouth can’t
move direct.

Norms: A person can identify the taste of bitter, sweet, and sour. (Estes, 2014)
Analysis: The patient’s sense of taste is normal as he was able to describe the taste of the last
food he consumed. Mouth structures are within normal but he inability to fully open his mouth,
based on his statement he experienced difficulty in swallowing fluids and solid food because he
has difficulty in opening his mouth fully due to the tetanus infection.

d.5 Sense of touch

To assess the sense of touch, the patient was instructed to close his eyes and asked to
determine sharp and blunt sensations in his arms using cotton ball and safety pin. He was able to
feel both sensations but pain is still persisted during assessment

Norms: The skin contains receptors for pain, touch, pressure, and temperature. Sensory signals
that help to determine precise locations on the skin are transmitted along rapid sensory pathways
and less distance signals such as pressure or poorly located touch are sent via slower or sensory
pathways. (Estes, 2014)

Analysis: The patient was able to feel and identify which area of his arm was touched and
responds if there are sharp or blunt sensations.

e. Motor Stability

During the assessment, he was able to stand with no assistance. He has not difficulties in
walking but slowly and he was not able to perform full range of motion on his lower extremities
because he is experiencing backpain as a symptoms of tetanus infection.

Norms: Patient should have a smooth and well-coordinated movement. Her hands should swing
freely on the side. A patient should have a normal gait, able to walk in smooth and steady
manner. Abnormal findings might have hand tremors, uncoordinated movement, stiffness,
shuffling, shoulders should not be slumped (Hinkle & Cheever, 2018)

Analysis: The patient is slowly moving/walking due to his condition (back pain )

f. Body Temperature
 Date and time Temperature Interpretation

November 26, 2021 37.8 ⁰C Hypherthermia ( above

8 am normal range )

November 27, 2021 36.9 ⁰C Normal

8am

November 28, 2021 36.8 ⁰C Normal

8 am

Upon Admission, his temperature is 37.8 degree was taken and showed abnormal result
and 2nd and 3rd day of checking temperature was within normal range .

Norms: Normally axillary temperature is within 36.4 to 37.4 centigrade (Berman et. al., 2018)

Analysis: His temperature for the 2nd and 3rd days was within the normal range but the first one is
above normal range it was result hyperthermia during the assessments based on the findings and
norms stated.

g. Respiratory Status

Date and time Respiratory Rate Interpretation

November 26, 2021 23 cpm Above normal range

8 am

November 27, 2021 19 cpm Normal

8 am

November 28, 2021 20 cpm Normal

 8 am

The patient’s respiratory rate upon assessment is 23 cpm while resting but the 2 nd and 3rd
day are within normal range . The patient’s chest is symmetrical and shape is in normal
appearance. The patient is using accessory muscle to breathe. Upon auscultation, he has a clear
lung sound.

Norms: A normal respiratory rate ranges from 12–20 CPM. Breathing does not require
noticeable effort. (Kozier and Erb’s 2015)

Analysis: The patient respiratory status for the 1st day was above normal range ( Tachypnea )
but the 2nd and 3rd day was normal. No signs of difficulty of breathing noted.

h. Circulatory Status

DATE TIME BLOOD PULSE CAPILLARY ANALYSIS

PRESSURE RATE REFILL
TIME

11/26/21 8:00 AM 130/70 mmHg 120 bpm 2 seconds NORMAL BP

NORMAL
PR

NORMAL
CAPILLARY
REFILL
TIME

‘11/27/21 8:00 AM 123/80 mmHg 98 bpm 2 seconds NORMAL BP

NORMAL
 PR

NORMAL
CAPILLARY
REFILL
TIME

11/28/21 8:00 AM 122/84 mmHg 95 bpm 2 seconds NORMAL BP

NORMAL
PR

NORMAL
CAPILLARY
REFILL
TIME

1st day of radial pulse assessment was initially noted at 120 bpm and regular and the 2 nd
and 3rd day assessment was normal. Auscultations of s1 and s2 heart sounds are normal. 1 st day
of Blood pressure reading was taken on the left arm with a reading of 130/70 mmHg and the 2 nd
and 3rd was within normal range. Capillary refill was normal.

Norms: Normal cardiac rate for an adult is 60-100 beats per minute while the normal blood
pressure is 120/80mmHg. (Kozier and Erb’s, 2015)

Analysis: 1st day of Pulse rate assessment was 120 bpm (tachycardia but regular rhythm) and
the 2nd and 3rd was normal 1st day of blood pressure assessment is above normal range
considered pre hypertension . but the 2 nd and 3rd day was normal. Capillary Refill assessment 1 st,
2nd and 3rd day was normal.

i. Nutritional Status

The patient stated his appetite is poor, he drinks 4-7 glasses of water and consumes three
meals but in a small amount, because he had trouble in swallowing as verbalized. He mostly eats
sweets and fatty foods. His weight status is normal with a BMI of 25.8.

Parameter Computation Norms Analysis

Height: 155 com Weight (kg) / Underweight Normal

[height(m)] ^2
Weight: 62 = <18.5

BMI: 25.8
Normal weight
= 18. 5 – 24.9

Overweight
= 25 – 29.9

Obesity
= >30
(Berman et, al.,
2018)

Norms: Normal eating pattern is considered to be at least three times a day depending on the
metabolic demands and needs of the patient. Fluid intake should be 8-10 glasses per day
(Monahan, 2017)

Analysis: His eating pattern is normal. Patient consumes three meals but in a small amount,
because he experienced difficulty in swallowing as verbalized. He has normal BMI.
j. Elimination Status
 According to the patient, he defecates once a day, every morning. He urinates nine times a
day, however as time passed by, Patient Complains he experienced urinary hesitancy and
difficulty starting his stream. The patient’s stool is brown.

Norms: Normal bowel movement of a person must be 1 to 2 times a day. A normal stool is
brown in color and well formed, urine is clear to yellowish in color. (Kozier and Erb’s, 2015)

Analysis: Normal findings

k. Reproductive Status

Mr FM stated that he is sexually active with no assistance of oral erectile agents, there is no
pain during intercourse as p verbalized and has not been diagnosed with any sexually transmitted
infection (STI).

Norms: The penile shaft and glans penis, Penile skin intact, appears slightly wrinkled and varies
in color as widely as other body skin Foreskin easily retractable from the glans penis. Urethral
meatus is pink and slit like in appearance and Positioned at the tip of the penis. (Kozier and
Erb’s, 2016)

Analysis: Normal findings

L. Sleep-Rest Pattern

He stated that he usually sleeps at least 8 hours, uninterrupted daily. He sleeps at 10:00 PM
and wakes up at 6:00AM every day. After work, he rests for an hour before taking his dinner.
However, because of his condition his sleeping pattern was affected.

Norms: An individual sleep for about 7-9 hours a day and takes a rest using some of activities
that will help you to relax including reading, watching television and others. Sleep refers to
altered consciousness with generation general showing of physiologic process while rest refers to
relaxation and calmness, both mental and physical (Estes, 2014)
Analysis: The patient’s sleep pattern is normal prior to admission, with 8 hours of sleep each
day. He has adequate sleep and rest. However, during confinement, he experienced a disturbance
in his sleeping pattern brought by the associated symptoms and adjustment to an unfamiliar
environment.

M. State of Skin Appendages

The patient skin is dry, intact and because of his temperature the patient skin is warm to
touch (37.8 degrees Celsius). He has a fair skin complexion. Upon performing the skin turgor on
both arms, it returns within 2-3 seconds. He has no presence of edema, but he has small wound
in his inflamed and bruised big toe was noted during physical examination.

Norms: Skin surfaces should not be tender, and the skin is dry with a minimum of perspiration.
Skin temperature should be warm and equal bilaterally, hands and feet maybe slightly cooler
than the rest of the body. Skin should normally feel smooth. The skin turgor should return within
2-3 seconds and edema should not normally present. The skin should be free from lesions and
inflammations. (Jensen, 2019).

Analysis: The patient has normal skin surface but warm to touch due to fever that is a known
part of the infectious process.