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13 Areas of Assessment

I. Social Status

Demographic Data

Mrs. Y is a 39 year old female, Born on August 1, 1970 via NSD by a midwife.
She is the eldest of the 11 siblings. The Family resides in Navotas Cardona, Rizal.
She has 5 offspring, 2 are working already while the remaining are still studying.

Socio-Economic Factor

Mrs. Y belongs in an extended family, Roman Catholic and a fish vendor,


while her husband works as a construction worker both are high school
undergraduate with a family income of 11,000.00 pesos per month which according
to Mrs. Y are just enough to meet their basic needs.

Environmental Factor

Mrs. Y resides in a medium size house made up of concrete with 3 rooms and
2 large windows which resulted to good ventilation. The house is located in a
congested area. Artesian well is their source of water. Their excreta disposal is with
water carriage.

Erick Erickson’s Psychosocial Theory

Based on Erickson’s psychosocial theory, Mrs. Y a young adult is classified


under Intimacy vs. Isolation which explains that the most important event are love
relationships, no matter how successful a person are, she is not developmentally
complete until she is capable of intimacy, on the other hand, an individual who has
not yet developed a sense of identity usually will fear a committed relationship and
may repeat to isolation.
In Mrs. Y’s case, she values her relationship with her husband. They have
been married for 24 years already and still they have a good loving relationship,
according to Mrs. Y, they try to solve things together to avoid fighting and they are
both emotionally attached to each other during hospitalization.

II. Mental Status

Mrs. Y is conscious and coherent, oriented to time and date, she is a high
school undergraduate and is able to read and write and follow instructions, able to
maintain eye to eye contact. Her chronological age is directly proportional to her
developmental age where her focus includes financial security, career and family
according to Sullivan’s stages of development. She is open and approachable and is
able to converse with the student nurses.
During Assessment, Mrs. Y talks about her childhood memories, showing that
her long term memories are still intact.
III. Emotional Status

Prior to hospitalization, according to Mrs. Y, she is very cheerful, she loves to


make conversations with their neighbors, sisters and her husband. During
hospitalization before the operation, Mrs. Y is still very cheerful and makes some
jokes during assessment.
After the operation, Mrs. Y became very irritable due to pain, but still she
stated that they don’t have any financial problem since her sisters and her husband
are very supportive not just financially but also emotionally. This shows that they
have a good relationship status with her family.

IV. Sensory Perception

Vision

In assessing the vision, patient is instructed to look straight to observe the


general appearance of her eyes. Eyes are almond in shape, irises are black in color,
and scleras are whitish in color, eyebrows and eyelashes are equally distributed.
Her conjunctiva is pale and moist, Patient is also instructed to follow the direction of
a finger with her eyes following six cardinal positions, and her eyes were able to
move in full range of motion and in all directions. With the use of a penlight Pupils
are assessed, Pupils are equally round and reactive to light accommodation. The
patient does not use eyeglasses or contact lenses.
visual acuity is assessed by asking the patient to read the word written in a
piece of paper with a font size of 12 about 3 feet away from her using the right eye
first then left eye and then both eyes.
Then test was repeated but this time it will be only 1 foot away from her
using the same procedure. Different words were use written in different paper in
every test. Mrs. Y read all the samples during the test.

Smell

Client’s nose has no deviation in terms of shape and size, nose is pointed and
no discharges were seen during assessment, according to the patient, she doesn’t
have any history of sinus infection or epitaxis.
Before the next procedure, permission was asked to the patient to do another
test, using a peeled apple and the skin of an orange, without the patient’s
knowledge, we ask her to identify the two samples by smelling. After smelling she
correctly identified the two fruits.
Test shows that there are no abnormalities or obstructions were identified in
the sense of smell.

Hearing

General appearance of Mrs. Y’s ears were parallel, symmetrically proportional


to the size of the head, bean shaped, firm cartilage and with a presence of
cerumen. In assessing the hearing acuity of the patient, Mrs. Y is instructed to
repeat the words that will be whisper at a distance of two feet away on the left ear
first, then right ear after the test, she was able to repeat the whispered words,
another test by the use of the beeping sound of our electronic thermometer at a
distance of 4 feet away and still she was able to hear the sound.
The test was repeated 3 days after the surgical procedure and the result was
the same. She verbalized that she has no known auditory deficits nor ear infection
history and unusual sensations like ringing or buzzing.

Taste

Mrs. Y’s lips were moist and symmetrical in shape; tongue is pinkish in color, no
presence of tooth
Decay, but there is a presence of tooth cavities, no dentures and no teeth loss, no
signs of gingivitis, buccal area are moist. We assess using a tongue depressor.
To assess her sense of taste, Patient is asked to do some test. She was asked
to taste a pinch of sugar and a pinch of iodized salt without knowing the two
samples are. After the test Mrs. Y identified the two samples correctly.

Touch

In assessing Mrs. Y’s sense of touch, she was asked to close her eyes, a
cotton ball was stroke to the back of her neck, then using another cotton ball, we
poured an alcohol on it and rubbed it on the same area, and she stated that she felt
a sensation of wet and cold on her skin.
Using the case of BP apparatus which is rough in texture and the medical kit
which is smooth in texture, the patient is asked to touch the two materials and ask
the texture while blindfolded. After the test, she correctly identified the difference of
two materials.

V. Motor Ability

Pre-operatively, patient is asked to perform R.O.M exercises on the upper and


lower extremities. She was asked to raise both her arms. She performed it with ease
and freely moves without any difficulty. She can bend and straightened her elbows
and extend and spread her fingers. She performed it with ease.
According to the patient, she usually has leg cramps that occur anytime of
the day especially when lying in high-fowlers position.
There are no presences of deformity; there are also proper symmetry
between left and right side of each extremity.
Post-operatively, the patient was instructed to remain flat on bed for a few
hours after surgery, and then early ambulation was encouraged. Patient can bend
her legs and arms with limited range of motion and needs assistance when standing
and going to the comfort room.

Patient Verbalized: “Sumasakit kasi yung opera ko kapag gumagalaw ako”


VI. Temperature

Date Time Temperature Location


September 21, 4pm 36.5 C Axilla
2009
September 22, 8am (pre) 36.4 C Axilla
2009
4pm (post) 37.0C Axilla
September 23, 6-2pm 38.0 C Axilla
2009 4pm 37.3 C

September 24, 4pm 36.8 C Axilla


2009

Mrs. Y’s is febrile In September 23; temperature is at 38.0 ‘C taken at Right


axilla.

VII. Respiratory Status

Date Time RR in Cycle per minute


September 21 2pm 17
September 22 8am (pre) 16
2pm (post) 18
September 23 2pm 23
September 24 2pm 18

Her chest expansion was symmetrical with ease during respiration. Rhythm
and respiration pattern are regular. She has an effective airway clearance and
effective breathing pattern which provide adequate gas exchange and results to a
good level of consciousness. Lungs were auscultated for adventitious sounds, after
auscultation, no adventitious sounds were heard. No supraclavicular or suprasternal
retraction were seen during inspiration

VIII. Circulatory Status

Date Time PR in Beats per minute


September 21 2pm 70
September 22 8am (pre) 73
2pm (post) 75
September 23 2pm 92
September 24 2pm 76

Taken at radial pulse, her capillary refill is within 1 to 2 seconds taken at right
forefinger, pulse scale is 2 + which is easily palpable.
Blood Pressure
Date and Time BP
September 21 120/80 mmHg
2pm
September 22 130/80 mmHg
8am
10:30am 100/60 mmHg
10:45am 110/70 mmHg
11:30am 100/70 mmHg
11:45am 120/80 mmHg
12:00pm 120/80 mmHg
12:30pm 120/80 mmHg
12:45pm 110/70 mmHg
1:00pm 120/90 mmHg
2:00pm 140/90 mmHg
September 23 130/90 mmHg
6 – 2pm
2 – 10pm 130/90 mmHg
September 24 130/90 mmHg
6 – 2pm
2 – 10pm 120/90 mmHg

Taken at her left brachial artery, negative for peripheral edema.

IX. Nutritional Status


Prior to hospitalization, Mrs. Y stated “Madalas isda ulam naming tapos
konting gulay kasi nga fish vendor ako”. She drinks about 7 to 9 glasses of water a
day. She has a good appetite prior to operation.
Prior to surgery she is on NPO, on the second day after surgery she was on a
soft diet but encourage eating nutritious food to help for her recovery. She eats
lugaw, biscuit and cupcake. The patient is with ongoing IVF of BMMS 1 liter x
30gtts/min.

Patient’s BMI

66.0kg
1.58m

=26.58 (overweight)

X. Elimination Status

Mrs. Y stated that prior to surgery; she defecates once a day every morning
with a semi-solid consistency without difficulty. She urinates 4 to 5 times a day
approximately 50 to 70cc per urination according to Mrs. Y’s statement. Urine is
amber in color.
After surgery, the patient has a diaper and IFC connected to urine bag with
amber color urine with a recorded urine output of 400cc with an IVF input of 700cc.
The IFC was removed on her 2nd day post-operation. She only defecates on the 3rd
day when she Dulcolax suppository was inserted.
She had a positive flatus but negative bowel movement in the first and second day
post-procedure.

1st Day Post Surgery 2nd Day Post Surgery 3rd day Post Surgery
>IFC was inserted. >IFC was removed. >Inserted Dulcolax
> (-) Bowel Movement >(-) Bowel Movement Suppository.
>(+) Flatus >(+) Flatus >(+) Bowel Movement

XI. Reproductive System

According to Mrs. Y, she had her menarche when she was 11 years old. With
an OB score of G7P5 (5025). She had 2 abortions more than 3 years ago because
according to Mrs. Y, she doesn’t want to have a child anymore. Abdominal Girth was
measured by using a tape measure, it measured 48cm. She had no history of any
surgical operations such as BTL and did not undergo Caesarian Section.
She uses oral contraceptive as her contraception or family planning method.
Prior to surgery, patient stated that she has vaginal bleeding with presence of
blood clot consuming 3 to 4 pads a day fully soaked with a bright red in color.
According to the patient her menstruation lasted 20 days that started in July of this
year accompanied with menstrual cramp and sometimes low back pain, her usual
menstrual period lasted 3 to 5 days.
Post-operatively, the patient stated “Dati nung di pa ako naooperahan
dinudugo ako at may konting buo-buo na dugo ngayon nawala na”.
XII. Physical Rest and Comfort

Prior to hospitalization, Mrs. Y sleeps 4 hours a day without any routine going
to sleep. She stated “Lagi akong puyat, apat na oras lang madalas ang tulog ko kasi
nagtitinda ako ng isda madaling araw pa lang, tapos basta may chance matulog ay
matutulog talaga ako kaso sandali lang talaga”.
Post-operatively, the patient usually sleeps within 6 to 8 hours at night and
wakes up during medication then she usually takes a nap at day time. Patient is
uncomfortable due to pain She stated during our post-op assessment to her
“pwedeng mamaya na lang, masakit talaga yung opera sa akin”. She usually lies on
bed.

XIII. State of skin and appendages

Skin

Prior to operation, Mrs. Y have good skin turgor with no history of skin allergy,
no presence of tattoo, no bed sore, no skin lesions. Patient has a fair complexion.
After the surgery, the client’s skin turned into a slight pale in color in the
second day, temperature is warm to touch but with good skin turgor, and no
presence of bedsore were seen.

Hair

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

“Hindi na ako nakakapaglinis ng katawan ko, ni hindi ko magawa ang makapagayos


o makapagsuklay man lang”, as verbalized by the patient

Nails

Prior to operation, Nails are pinkish in color, no signs of clubbing.

Breast

In assessing the breast, the patient is asked to do self breast examination,


drape was provided for the patient for privacy. According to the patient she didn’t
feel any mass or lumps in her breast. She also stated that she didn’t have any
history of bleeding and nipple tenderness.

Extremities

the patient was assessed for homan’s Signs; her legs was dorsiflexed, after
the test, the patient did not feel any calf pain and she don’t have any signs of
thrombophlebitis and edema in the lower extremities.
Pain

Prior to hospitalization, the patient stated “kapag meron ako, kumikirot lagi
puson ko”

➢ Severity of pain according to patient’s perception of pain is 3 to 4


(painscale of 1 to 10)
➢ Precipitating factor: Occurs during menstruation
➢ Alleviating factor: Drinking medications
➢ Related symptoms: None

Post-operatively, the patient stated “Masakit yung opera ko, kumikirot


talaga”. The pain occurs anytime at the abdominal area with a pain scale of 6
to 7 according to patient’s perception of pain, pain worse when moving or
standing according to the patient, pain is alleviated by medication or lying on
bed.

Neck

Prior to operation, patient has no enlarged lymph nodes nor pain or stiffness
and no thyroid enlargement. After the operation, patient’s lymph nodes become
palpable.

NURSING PROBLEMS

The following are the nursing problems that have been established during
assessment.

➢ Acute pain related to effects of surgery as manifested by


irritability
➢ Self-care deficit, Hygiene/bathing related to activity
intolerance as manifested by inability to perform the most
basic physical task and personal care activities
➢ Bowel incontinence related to laxative as manifested by
inability to urge to defecate.
NURSING CARE PLAN

SUBJECTIVE PLANNING INTERVENTION RATIONALE GOAL


“Ang sakit ng tahi, -After 4 hours of NIC, INDEPENDENT
masakit talaga” patient’s feeling of --Encourage -Pain is subjective – Goal is met,
-pain scale of 7/10 pain will alleviate Verbalization of data which cannot be pain has
from pain scale of 7 feelings felt by others. alleviated from
Objective: to 5. -for baseline data. pain scale of 7
-Irritability -Monitor v/s to 5 as
-Facial grimace evidence by
-limited attention -Helps to minimize patient’s
span -Position change and pain. reaction to
-Increased v/s back rubs. pain and
(RR,BP,PR,Temp) progress of v/s
after 4 hours
-Encourage deep -To promote of NIC.
breathing exercise relaxation

-Encourage activities
that will divert -To diverts’ patients’
attention like perception of pain.
listening to music or
reading magazine.

-Encourage pt. to -Timely intervention


report pain as soon is more likely to be
as possible. successful in
alleviating the pain.

-To prevent fatigue


-Encourage rest
period.
-To reduce pain
DEPENDENT
-Administer pain
reliever as prescribed
such as Toradol.
-To determine if
COLLABORATIVE there is
-Notify physician if complications and
measures are find possible
unsuccessful or if intervention
current complaint is a necessary for the pt.
significant change collaboratively with
from patients past the physician.
experience of pain.

Nursing diagnosis: Acute Pain related to effects of surgery as manifested by irritability


Subjective Planning Nursing Intervention Rationale Goal
“Sumasakit kasi yung After 4 hours of NIC, Independent: Goal met.
opera ko kapag the patient will be
gumagalaw ako” able to do activities > Evaluate > To provide baseline The patients was able
of daily living within limitations of actions data to do activities of
Pain scale of 7 out of her capabilities and and Monitor V/S daily living within her
10 patient will be able to capabilities
attain good hygiene And attain good
Objective: with the assistance of hygiene
-Slow movement Significant others and > Planned care with After 4 hours of NIC
-Increased RR, BP, PR nurse assigned. rest periods between > To reduce fatigue
-uncombed hair activities
-presence of
seborrhea

> Assisted patient > To protect patient


with activities (self-
care) from injury

>Cleaning the body >for the purpose of


of the patient. relaxation and
cleanliness

>provide assistance
until patient is fully >lessens effort
able to assume self-
care

>placed things within


reach like comb. >lessens effort

Dependent:

-administer pain
reliever as prescribed
such as toradol prior -to reduced pain
to bathing

Collaborative:

>Instructed and
assisted SO to clean
the patient’s body
>Promote grooming
with a wet towel of patient

>Stressed and
performed proper
hygiene and
grooming

to patient

Diagnosis: Self-care deficit, Hygiene/bathing related to activity intolerance as manifested


by inability to perform the most basic physical task and personal care activities

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