13 AREAS of ASSESSMENT/ REVIEW of SYSTEM

1. Psychosocial Status

Patient X is a 44-year-old, Filipino female, a resident of Purok 8 Green Valley, Dontogan,

Baguio City. She was admitted on July 24, 2023 @ 12:01 am with an admitting diagnosis of Intracranial,

Extra-Axial Mass, Right Temporal Convexity t/c Meningioma vs Metastatic. The patient and her family

are Roman Catholic and had no practices or beliefs that could interfere with receiving medical care.

2. Mental and Emotional Status

The patient is unconscious, not alert, and incoherent. She is not responsive to verbal

stimuli, light, and pain stimuli. She is not oriented to current time, date, and place.

3. Environmental Status

Patient is not aware of her surroundings. The room has poor ventilation, and has

confined space for patients. It doesn’t have adequate lighting. There is a side table provided to place

food and other needs which is accessible for her significant others.

4. Sensory Status

a. Visual Status

- On the assessment of the patient’s visual status, there is a presence of anisocoria.

She is unresponsive to light and accommodation. Upon inspection of the eyes, there

is a sign of conjunctival irritation or redness.

b. Auditory Status

- During assessment, there were no signs of inflammation, swelling or infection.

There are no obstructions, signs of lumps and discharges. The patient was not able

to distinguish voices and no response upon hearing them.

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c. Gustatory Status

- The patient was not able to distinguish different tastes or flavor through the foods

she consumes during hospital stay as she is unconscious and was fed via PEG tube.

d. Tactile Status

- During assessment, the patient was not able to feel heat, cold, ang pain sensations.

The patient was not able to perceived different types of touch sensations when

stimulated with the use of pen and is not responsive to touch when taking the vital

signs. The patient doesn’t have the ability to smile, close eyes, and wrinkles

forehead noting facial sensation not intact.

e. Sensory Environment

She cannot distinguish voices even from a distance, loud or soft. The patient is not

able to discriminate an odor from the other.

5. Motor Status

Reduced motor function noted. Motor strength of both upper extremities noted at 0%,

with limited passive ROM, unable to do ADL’s and requires full assistance.

6. Nutritional Status

Patient is on osterized feeding via PEG tube.

7. Elimination Status

During the course of duty, patient has passed stool two times. She excretes an

average amount of 1200 ml urine per day, noting a yellowish urine via IFC.

8. Fluids and Electrolytes

Patient was hooked to PNSS 1L x 12 hours. She was able to consume 1000 ml a day.
9. Circulatory Status

The pulse rate during the shift is between 80-90 beats per minute which is in normal

range. The pulse was weak with an irregular rhythm. Patient has a capillary refill of

more than 3 seconds.

10. Respiratory Status

- The patient’s respiratory rate ranges from 15-19 cycles per minute. Impaired

spontaneous ventilation was noted due to decreased respiratory function. The

patient is dependent on mechanical ventilator.

11. Temperature Status

Patient’s temporal temperature normally ranges from 36.7-37.2 degrees Celsius.

There is no sign of profuse sweating or chills. The environmental temperature is

warm and humid.

12. Integumentary Status

Skin color is brown and has dry skin. She has a poor skin turgor @ greater than 3

seconds. The PEG tube is intact. With ulceration in the sacral area with minimal

bleeding.

13. Comfort and Rest Status

The patient’s bed position is adjusted to semi-fowlers according to comfort. Log

rolling was done every 2 hours.