I. 1.

Psychosocial Status

13 AREAS OF ASSESSMENT

Patient is a 32 years old resident of 56 Bayan Park Aurora Hill, Baguio City. Patient verbalized that he currently provides his basic needs by working as a radio technician. His wife and relatives are always around helping him in doing his activities of daily living. Patient is practicing Catholic. He believes that his current condition is due to the effects of alcohol and believes that he could overcome it. 2. Mental and Emotional Status Patient was seen awake and not in any signs of cardiopulmonary distress. He is conversant, coherent and responds appropriately to verbal and non-verbal stimuli. He is well oriented to time, place and person. He is able to initiate limited activity and is able to show response to pain stimuli. During the interview, he is able to express his feelings and uses clear words. But during intake of Diazepam, the patient experience hallucination. He reported that he sees things that others cannot see. He was able to finish college degree. He can read nor write. He can understand English and Tagalog. As to his condition, he believes that his condition is trial that could be overcome. Patient appears neat, wearing clean clothes. Nails are tidy with no signs of keratinization. Hair is also well-groomed. 3. Environmental Status Patient is well oriented to the environment and is familiar with the room set-up. He has intravenous access on his right arm for his IV fluids that may potentially expose her to infection and lines may limit her general mobility. Bed rails are available. Patient and family members claim that they dispose their garbage properly. Alcohol was available at bedside for disinfection. The patient is in medical extension ward. It is adequately ventilated. No unnecessary noise was noted. It is also spacious and there are other patients. The floor was also well maintained and non-slippery. No scatter rugs were seen. Other than that, patient has no complaints of uneasiness or discomfort concerning his environment.

The home environment, as reported, is a concrete type of house with four rooms and one comfort room. It is located near the road, thus, making his house expose to dust and noise. 4. Sensory Status a. Visual Status Patient has yellowish palpebral conjunctiva. He is able to move eyes without tenderness, pain or difficulty. b. Auditory Status Upon assessment, no visible lumps or lesions noted, corrective devices used such as hearing aids and discharges were noted. c. Olfactory Status The patient has intact sense of smell as manifested by the ability to distinguish familiar odor such as alcohol during assessment. No epistaxis was noted. Nose was seen to be symmetrical, proportionate and no lesions seen. d. Gustatory Status Patient is not using dentures. According to him, he has decrease sense of taste. He has slight dry lips and oral mucosa. There is no difficulty in masticating and swallowing as verbalized. He has intact gag reflex. e. Tactile Status Facial sensations are also intact and symmetrical on both sides. He is able to perceived heat, cold and pain sensations. f. Language Perception and Formation The patient is able to initiate and understand speech by giving queries on current health condition and answering questions asked by the student nurse. g. Sensory Environment

Environment is well ventilated. Ward is spacious and no unnecessary noises were observed. Patient has no complaints of discomfort concerning his environment. 5. Motor Status Patient is on sitting position with slightly limited movement. He has muscle strength of 3/5 on both upper and lower extremities, which means that he has limited movement against gravity and some resistance. Further, no tremors and deformities noted on both upper and lower extremities. Upper extremities are symmetrical as well as the lower extremities. Peripheral pulses were present such as radial. No crepitus noted upon flexion of joints. Extremities are warm to touch. 6. Nutritional Status The patients skin appears to be dry; he has a good skin turgor that returns in 1-2 seconds. Hair is noted to be terminal in the scalp, eyelashes and eyebrows with no parasite infestation. Patient has slightly dry lips and oral mucosa. The patient has poor appetite in eating; he consumes 30% of food served. The patient has a medium body built. Patient sees foods as a source of energy and verbalized that he has no religious restrictions about food as well as allergies. The patient has a high protein diet and low sodium diet, as ordered by the physician. Bowel sounds are as follows: RUQ: 4, RLQ: 2. LUQ: 6; LLQ: 4, upon auscultation. It reveals normal bowel sounds per minute. Abdomen is globular upon inspection and nontender in all four quadrants upon palpation. 7. Elimination Status Patients frequency of urination is estimated to be 3 times per shift at approximately 750 cc. He uses the bathroom with assistance and privacy is observed. No pain was reported to be felt during urination. Urinalysis revealed clear and dark yellow urine with a specific gravity of 1.030 is used as an indicator of the kidneys ability to excrete concentrated urine. As particle increases, so does the specific gravity. 8. Fluid and Electrolyte Status Patient is able to consume 350 cc of water. He is hooked to D5LRS 1L+ 2 amps. Vit. B complex x 12 hrs, regulated at 83-84 gtts/min. He has dry lips. He has a good skin

turgor; skin and hair are slightly dry. Patients skin is brownish and has pinkish nail beds. No signs of dehydration noted as well as edema formation. 9. Circulatory Status Patient has pulse rate of 69 beats per minute and a blood pressure of 110/70 mmHg while positions on semi fowlers. He has normal capillary refill of 1-2 seconds. He is not cyanotic. He has a history of cigarette smoking and alcohol drinking. 10. Respiratory Status

He has a respiratory rate of 20 breaths per minute. No use of accessory muscles noted. Chest wall symmetrically expands with each respiration and no retractions see. The patient has history of cigarette smoking and alcohol drinking. 11. Temperature Status

The patient verbalized feeling of warmth and cold. His temperature is 37.6OC, per axillary upon the initial vital signs taking. The ward is adequately ventilated. The patient, as well, had used only one blanket, with clothes made of cotton not greatly affecting the clients temperature status. 12. Integumentary Status

Patients skin is dry generally white, without pigmentations, no pallor, jaundice or cyanosis. He has good skin turgor. His nail base is soft when palpated, with capillary refill of 1-2 seconds. His hairs are dry, evenly distributed, no parasite infestations, and well-trimmed. 13. Comfort and Rest Status

The patient sleeps experience sleep disturbance, as reported.