13 AREAS OF ASSESSMENT

I. PSYCHOLOGICAL

Ms. M.I a 35 years old female patient born on February 24 1988. She and her Children currently
living in Salvacion Pio V. Corpus. The patient and her family is Baptist and have no practices or
beliefs Which might affect to providing health care.

II. MENTAL AND EMOTIONAL STATUS

Patient I. is onented to time, place and person She can actively communicate with us and able
to speak Tagalog and bisaya. She is responsive and answers to the questions being ask She
cooperates and relaxed while performing she interview She stated that she does not feel any
fear regarding her condition. She accepted it and stated that every individual has an end. She
believes that everything has a reason and said that is in God's plan. Patient I. just prayed that
she will not suffer too much pain from her condition

III. ENVIRONMENTAL STATUS

there are no sensory deficits and she is oriented that she is in the hospital Patient is
knowledgeable about her conditions. There is steady pattem of activity, light noise and color in
his environment and it does not distract her. She is comfortable during sleep. The food and
water or side table is placed at the left side of the patient it is accessible for her needs

IV. SENSORY STATUS

There is no known visual deficit like color blindness. She can also distinguish voice even from a
distance, loud or soft. No corrective auditory deficits And no auditory device noted being used
by the patient.

V. MOTOR STATUS

Motor strength is assessed Her movements are limited. The patient is able to move and can
move all her joints slowly and carefully as of the moment. No prosthetic device was noted
present with the patient and all her extremities are intact

VI. NUTRITIONAL STATUS

The patient food is being served in the hospital and she is in DAT. There is no change in the
appetite in eating during the hospitalization and health. There is no culture or religious dietary
restriction reported by the patient. The patient is eating orally by herself.
VII. ELIMANITION STATUS

The patient eliminates in a toilet bowl once a day. The stool is usually brownish and semi solid.
She drinks water to aid her elimination. She verbalized that she frequently urinates during her
stay at the hospital. She urinated 1-2 times during my shift. She usually consumes 5-6 or more
glasses of water per day.

VIII. Fluid and Electrolyte Status

Patient stated she was drinking water, about 2 to 3 glasses of water per day and has an
ongoing IVF of PNSS x1L regulated at 15 to 20 gtts/min. The patient denies the feeling of thirst.
Her skin turgor is normal and she has moist mouth and mucous membranes. The patient's
capillary refill is 1-2 seconds.

IX. CIRCULATORY STATUS

The pulse rate during the shift is 116 beats per minute which is not the normal range. With
regards to emotional stress and physical activity, the pulse rate increases. The patient's blood
pressure is 160/120 . This was taken while the patient is lying down in the bed.

X. Respiratory status

Her respiratory rate is 21 breaths per minute with no use of accessory muscles. There is no
abnormal breath sounds heard. The patient's lip's color is pinkish but slightly dry along with her
nails.

XI, Temperature Status

Patient's axillary temperatures is 37.2 C. There is no sign of profuse sweating or even irritated.
The environmental temperature is cold and the humidity is high and the patient is comfortable
with it.

XII. Integumentary Status

The patient's skin is dry and white, with no pigmentation, pallor, jaundice, or cyanosis. She has
healthy skin turgor. When his nail base is palpated, it is soft, with a capillary refill time of1-2
seconds.

XIII. Comfort and Rest Status

The patient claims that normally she sleeps 8-10 hours in a day. Her sleep was now only 6-7
hours during hospitalization. She claims that she is very comfortable with her sleep even if she
is in the ward but sometimes being disturbed when nurses have to get her vital signs or give
medications.