13 AREAS OF ASSESSMENT

1. SOCIAL STATUS

Mr. R is 44 years old, born on January 20, 1969. He resides at Paranaque City. He and his
recent live-in partner run off from their families in Paranaque for almost ten years. But then at
the end theyve been separated because of financial issues and his disease. He came back to his
family to ask for their support and he didnt failed. For 10 years of living with his former lived in
partner he experienced working in a junk shop to be able to survive and stayed in squatter area.
He doesnt smoke neither drink alcohol beverages. Due to his illness his lifestyle is affected.
Before he had his disease, patient was socially active, but at present he was not able to mingle
with his neighbor and go to other places he wants to go.

Norms:
Social status includes family relationships/friendships that state the patients support
system in time of stress and in time of need. It meets a fundamental human need for social ties,
making life less stressful and social support buffers the negative effects of stress, thus indicating
indirectly contributing to good health outcomes. (Friedman and Smith 1988)
Analysis:
Based on the above statements Mr. R social status is affected by his condition. With his
condition forces him to restrain from interactions outside home.

2. MENTAL STATUS

Mr. R is conscious and coherent. He is also oriented to time, place and person.
According to his sister, he can identify things or names being asked. He can recall recent and
remote memories he experienced. He is able to read and write and can speak in English and
Filipino language. He was a high school graduate. He can also answered question being asked by
his sister.

Norms:
The content of the patient message should make sense. The ability to read and write
should match the patients educational level. The patient should be able to correctly respond to
questions and to identify all the objects as requested. The patient should be able to evaluate
and act appropriately in situations requiring judgment. (Health assessment and
physical examination3rd edition by Mary Ellen Zator Estes)
Analysis:
Being responsive and being able to answer questions accordingly is the
major determinants which indicate patients mental capabilities are still functioning well.

3. EMOTIONAL STATUS

Mr. R is cooperative and relaxed while performing the interview. He stated that he does
not feel any fear regarding his condition. He accepted it and stated that every individual has an
end. He believes that everything has a reason and said that everything is in Gods plan. Mr. R
just prayed that he will not suffer too much pain from his condition.
Norms:
The adulthood is in the stage where an issue of Generativity - Stagnation arises. This
stage takes place during middle adulthood between the ages of approximately 40 and 65.
During this time, adults strive to create or nurture things that will outlast them; often by having
children or contributing to positive changes that benefits other people.
Analysis:

The fact that the patient shows acceptance regarding his current health condition
shows that he is emotionally stable and reacts accordingly. He believes that his life is part of
Gods will and everything that happens to him has a reason.

4. SENSORY PERCEPTION

A. Ears (Hearing)

Both right and left ears are normal, because he never ask to repeat any of my questions.
The clients ears were symmetrical. No presence of infection.

B. Eyes (Vision)

Both right and left eye were assessed. The clients eyes were symmetrical. No redness or
swelling seen, black in color. He has a both poor eye sight. His left side eye is more blurred
than his right eye. According to his sister, his left eye has a vision of 150 while his right side
eye was 100 visions. He has dark circles under his eyes because he cant sleep well due to his
condition.

C. Nose (Smell)

His sense of smell is normal and he can distinguish foul and fresh odors.

D. Mouth (Taste)

His lips are light brown in color. His tongue is slightly pink. And he can taste whatever
food he eats.

E. Touch

The client was able to identify sharp and dull objects as well as warm and cold.

F. Speech

The client can able to talk and last long for about 15-20minutes. He cannot talk longer
than that due to his condition.

Norms:
Each of the six senses becomes less efficient in adulthood. Changes result in loss of
visual acuity, less power of adaptation to darkness and dim light, decreased in
accommodation to near and far objects. Gradual loss of hearing is more common among man
than women, perhaps because men are more frequently in noisy work environments. Older
people have a poorer sense of taste and smell and are less stimulated by food than the young.
Loss of skin receptors takes place gradually, producing an increased threshold for sensations
of pain, touch, and temperature. (Fundamental of Nursing 7
th
edition Barbara Kozier)
Analysis:
Mr. Rs blurring of her vision is due to aging process. The sense of smell, taste and
hearing, touch, speech can perceive stimuli accordingly.
5. MOTOR ABILITY

The client has difficulty in moving and needs assistance in transferring from bed to chair.

Norms:
Adulthood is in the stage where neuron loss continues with associated decrease in
cerebral flow. Reaction times slow due to decreased levels of neurotransmitter. Gait and
balance are affected with decreased proper conception. (Focus on Pathophysiology by Bullock
and Henze).
Analysis:
Due to his present condition and also due to age, the patient has difficulty in
coordinating movements as well as performing ADLs.
6. BODY TEMPERATURE

The table below shows the temperature of Mrs. R during the shift:
Date Time Temperature Site Analysis
February 19, 2013
8:00am 36.33 Axilla Normal
12:00nn 36.4 Axilla Normal
February 20, 2013
8:00am 36.8 Axilla Normal
12:00nn 36.7 Axilla Normal



Norms:
Normal axillary temperature is within 36.5C to 37.5C. (Health assessment and physical
examination 3rd edition by Mary Ellen Zator Estes)
Analysis:
During the interview, the patient had a body temperature of 36.33 degree Celsius at the
axillary site. The patient is afebrile.

7. RESPIRATORY STATUS

Table below shows the respiratory rate of the patient:
Date Time Respiratory Rate Analysis
February 19, 2013
8:00am 24 Abnormal
12:00nn 25 Abnormal
February 20, 2013
8:00am 26 Abnormal
12:00nn 25 Abnormal

Norms:
Normal respiratory rate for adults is 12-20cpm. Average is 18. In terms of pattern,
normal respirations must be regular and even in rhythm. The normal depth of respirations is
non-exaggerated and effortless. (Health assessment and physical examination 3rd edition Mary
Ellen Zator Estes)
Analysis:
During the interview, the patient has a respiratory status of 24 cycles per minute. He
had an oxygen tank beside his bed but the patient didnt use it because according to his sister he
can breathe normally but as we observed the patient was suffering from bearable difficulty of
breathing.

8. CIRCULATORY STATUS

The circulatory status of the patient as well as blood pressure noted below:
Date Time Pulse Rate Analysis
February 19, 2013
8:00am 65 Normal
12:00nn 68 Normal
February 20, 2013
8:00am 69 Normal
12:00nn 73 Normal

Date Time Blood Pressure Analysis
February 19, 2013
8:00am 100/70 Normal
12:00nn 110/70 Normal
February 20, 2013
8:00am 110/70 Normal
12:00nn 100/70 Normal

Norms:
Normal cardiac rate for an adult is 60-100 beats per minute while the normal blood
pressure is 120/80 mmHg. The working capacity of the heart diminishes with aging. The heart
rate of older people is slow to respond to stress and slow to return to normal after stress.
Reduced arterial elasticity results in diminished blood supply to the parts of the body especially
the extremities. (Kozier et. al, 2004)
Analysis:

The patient had a blood pressure of 100/70 mmHg and pulse rate of 65 beats per
minute. And the capillary nail refill test was perform there was good blood flow to the nail bed,
a pink color returned in less than 2 seconds after pressure is removed.

9. NUTRITIONAL STATUS

Prior to admission Mr. R, intake of meal is three times a day. The food served is usually
vegetables, fish and sometimes meat but because of his disease he experienced loss of appetite.
During admission, he was advised by the attending physician to eat diet as tolerated.

Weight: 50kg
Height: 54ft = 165cm (1.65m)

BMI = Weight in kilograms
(Height in meters)
2



BMI Calculation: 50 (1.65)
2
=
50 2.7 = 18.5 is normal

Norms:

Less than 18.5 are underweight
18.5 22.9 are normal
More than 23 are Overweight

Analysis:

The body Mass Index (BMI) is 18.5 it is within normal range.




10. ELIMINATION STATUS

BLADDER: Before his admission Mr. R usually urinates 6 to 7 times a day with a range of
2-3 L. Urine is yellow in color and doesnt feel any discomfort or pain whenever he urinates.
During his hospitalization, he urinates 2-3 times a day with a range of 2-3L. Urine is still amber in
color. Doesnt feel any discomfort whenever he urinates.

BOWEL: Before his admission Mr. R usually defecates 4-5 times a week. Stool is solid
and is in minimal amount and brown in color.He doesnt feel any discomfort or pain whenever
he defecates. During his hospitalization he defecates once a day still in solid form and brown
color and doesnt feel any discomfort.

Norms:

BLADDER: The frequency of urine varies with the amount of fluid intake.
Color: Transparent, whitish, amber. Odor: Aromatic (Kozier, pg. 126)Absence of pain and
discomforts (Kozier, pg. 1227)

BOWEL: The frequency of defecation us highly individual, varying from several times per
day or 2 3 times per week. (Kozier, pg. 1226)
Color: brown. Consistency: formed, soft, semi-solid. Shape: not less than 1 inch (Kozier, pg.
1227)

Analysis:

Nothing to worry about, his output.

11. REPRODUCTIVE STATUS

Mr. R had his circumcision when he was 13 years old. Patient first sexual contact was his
recently former lived in partner and had only one sexual partner in his entire life.

Norms:
Ability to make autonomous decisions about ones sexual life within a context of
personal and social ethics.Knowledge about sexuality and sexual behavior. (Kozier, pg. 973)
Analysis:
As based from the above information, patient has a normal reproductive status.
12. STATE OF PHYSICAL REST AND COMFORT

He usually sleeps at 9:30pm and wakes up 6:30am for about 8 to 9 hours a day but
when he had his disease he experience sleep disturbances due to his condition. According to his
sister, his sleeps was interrupted in the middle of the night when he experiencing difficulty of
breath and due to productive coughing. He also takes a nap in the afternoon twice a day for
about 30minutes. He had hard time to sleep thats why he just listens to music for easy sleep
pattern.

Norms:
Most adult require 8 to 10 hours of sleep at night to prevent undue fatigue and
susceptibility to infections. (Kozier, 1116)Make sure the room is dark and comfortable.(Kozier,
2004)No prominent eye bags.(Kozier, 2004)

Analysis:

Patient has a difficulty in sleeping and experiences sleep disturbances due to his
condition. His sleep was being interrupted in the middle of the night.

13. STATE OF SKIN AND APPENDAGES

Skin
Mr. R has a good skin turgor with no history of skin allergy, no presence of tattoo, no
bed sore, and no skin lesions. Patient has a brown complexion.

Hair

Presences of dandruff werent seen during assessment, no lice were seen, and patient
has a thick and wavy hair.

Nails

Nails beds are pinkish in color, no signs of clubbing.
Extremities
The patient was assessed for homans Sign; his legs was dorsiflexed, after the test, the
patient did not feel any calf pain and he does not have any signs of thrombophlebitis and edema
in the lower extremities.
Neck
Patient has no enlarged lymph nodes nor pain or stiffness and no thyroid enlargement.
Analysis:

Mr. R skin is brown in color, dry with a minimum of perspiration and has no lesion at any
surfaces which are normal state condition. Its texture is slightly wrinkled and roughness is also
observed due to his oldness. The clients thumb elasticity when pinched slowly turns to its
original contour. There is also no edema present in any surface of the body.