1.

Psychosocial and Psychological Status

In Erik Erikson’s Stages of Psychosocial Development, the patient falls under Itimacy vs. Isolation since this stage is
applicable to young adult. Patient is a 33-year-old male, a Roman Catholic from #555 Lower Quirino Hill, Baguio City.
Patient is known also to be active. In the Nine Developmental Stages, the patient is at the Young Adulthood stage which
comprises adults aged from eighteen to 40 years old. While many people are at the height of their production in both love
and work, aging, which started earlier, also becomes more apparent around this time. As well as being more realistic about
previously assumed life possibilities, it can also be a moment to distinguish between what is likely and what is possible.

2. Mental and Emotional Status

The patient is conscious, alert and coherent. He is very responsive in verbal stimuli, noise, light, touch and pain
stimuli. He is oriented to current time, date and place. He acts according to his age. He has good perception about her
health. He is very cooperative and prevents somethings to further cause damage to his health. No social concerns or fears
were noted and no medicines or substances were taken to alter emotional response. He verbalized that he is not stressed
but very bored.
III. Environment Status
There are no sensory deficits and he is oriented that he is in the hospital. Patient is knowledgeable about his conditions.
There is steady pattern of activity, light noise and color in his environment and it does not distract him. He is comfortable
during sleep. The food and water or side table is placed at the left side of the patient it is accessible for his needs. Patient
is in the orthopedic ward, together with his watcher.
IV. Sensory Status
There is no known visual deficit like color blindness. He 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. The patient is able to discriminate an
odor from the other. The patient is able to discriminate sweet, sour, salty and bitter tastes from each other. With regards to
the patient’s tactile status, he was able to determine that the patient is able to discriminate sharp and dull, light and firm
touch, able to perceive heat, cold, pain in proportion to stimulus, able to differentiate common objects by touch by doing
necessary procedure. Patient has an intact body image and there is no aberrant sensation.
V. Motor Status
Motor strength is assessed. His movements are limited since he undergone an operation and his right arm was being
casted. The patient is able to move and can move all his joints slowly and carefully as of the moment. He verbalized that
his watcher can assist him whenever he needs something.
VI. Thermoregulatory Status
Date Time Temperature Finding and Implication
May 1, 2023 10 am 36.5 Patient’s body temperature on
2pm 37.5 the morning was in the normal
range

VII. Respiratory status

Date Time Temperature Finding and Implication
May 1, 2023 10 am 20 Patient’s respiratory rate is is
2pm 19 normal range.

VIII. Oxygen Saturation Status

Date Time Temperature Finding and Implication
May 1, 2023 10 am 97% Patient’s oxygen saturation
2pm 96% level is in the normal range.

IX. Nutritional Status

The patient food is being served in the hospital. The patient appetite is good. There is no change in the appetite in eating
during the hospitalization and health deviation. Teeth are complete without dental carries. The nails were fine and well-
trimmed. There is no culture or religious dietary restriction reported by the patient. The patient denied any indigestion,
vomiting. The patient is able to swallow in his food and eat orally by himself.
X. Elimination Status
The patient eliminates in a toilet bowl once a day. The stool is usually brownish and semisolid. He drinks water to aid his
elimination. He verbalized that he frequently urinates during his stay at the hospital. He urinated 1-2 times during my
shift. He usually consumes 5-6 or more glasses of water per day. The patient claimed absence of special problem like
urinary and bowel retention, urinary incontinence and diarrhea. Patient denies feeling of thirst.
XI. Sleep, Rest, and Comfort Status
The patient claims that normally he sleeps 8-10 hours in a day. His sleep was now only 6-7 hours during hospitalization.
He claims that he is very comfortable with his sleep even if he is in the ward but sometimes being disturbed when nurses
have to get her vital signs or give medications.
XII. Fluid and Electrolyte Status
The patient usually drinks 5-6 glasses only of water daily and urinates regularly. He has an ongoing IVF of PNSS 1L and
being regulated on ______ gtts./min. The patient denies the feeling of thirst. His skin turgor is normal and he has moist
mouth and mucous membranes. The patient’s capillary refill is 1-2 seconds.
XIII. Integumentary Status
Skin color is brownish and has a good skin turgor at 1- 2 secs. There are no wounds noted or reported by the patient. The
dressing is dry and intact and sometimes. Nails and hair are well kept by the patient. There are no odorous secretions or
oily secretions.