Name: DEGAN, DAWN C.

Date: September 20, 2019

Year/Section: BSN-2, 4-B CI: Ma’am Ayson Benita

TITLE: THIRTEEN AREAS OF ASSESMENT

1. PSYCHOLOGICAL STATUS:

Patient M.J is a 32-year-old female and married. She has two

children including the new born. She is presently residing at Irisan,
Baguio City. The patient and her family is a Roman Catholic and no
practices or beliefs which might affect on providing care. She is
slightly in terms of her health to her husband and the health care
professionals. Talking to her husband and tot the other patient near
bed in the OB ward is her way in spending her leisure in the hospital.
She has positive outlook with her life.

2. MENTAL AND EMOTIONAL STATUS:

The patient is conscious and coherent. She is responsive in verbal,

touch and pain stimuli. She was oriented with the current time,
place and date. The patient was cooperative and responding to all
the questions being asked. She verbalized that is not stress but in
pain with the scale of 5 out of 10 and have inadequate sleep.

3. ENVIRONMENTAL STATUS:

The patient is conscious and oriented that she is in the hospital. She
is in the OB ward (Benguet General Hospital) together with her
husband. Light noise, color and her surrounding doesn’t distract her.
She also stated that she is comfortable when sleeping and during
asleep. Food, water and prescribed medicine are place on the
table at the right side of the patient’s bed and it is accessible to her
needs. She is also near the window where she sometimes looks out.

4. SENSORY STATUS:

a) VISUAL STATUS
- There is no known visual deficit like color blindness and
cataracts.
b) AUDITORY STATUS
- The patient doesn’t have corrective deficit and auditory
device.
c) OLFACTORY STATUS
- The patient is able to discriminate or differentiate odor from
the other.
 d) GUSTATORY STATUS
- The patient is able to discriminate or differentiate the flavors
such as; sweet, bitter, sour and umami taste from each other.
e) TACTILE STATUS
- With regards to the patient’s tactile status, she is able to
discriminate objects that is sharp and dull with light or firm
touch. She is also able to perceived heat, cold and pain.

5. MOTOR STATUS:

The motor status of patient M.J is slightly limited since she

undergone delivery (postpartum) and that she has an episiotomy.
The patient is able to move slowly and carefully as of the moment,
there are no prosthetic device noted or observed. She verbalized
the whenever her husband is with her, he assists her in whenever she
needs something.

6. THERMOREGULATORY STATUS:

DATE TIME TEMPERATURE

Sept. 16, 2019 3:00 pm 36.7
6:00 pm 36.6
10:00 pm 36.7

The table represents the temperature of patient M.J during

her hospitalization and her temperature is normal.

7. RESPIRATORY STATUS:

DATE TIME R. R SPO2

Sept. 16, 2019 3:00 pm 19 98
6:00 pm 19 95
10:00 pm 18 98

The table represent the temperature of patient M.J during her

hospitalization. Her respiratory rate is normal (12-20) and her oxygen
saturation is also normal (96-99)

8. CIRCULATORY STATUS:

DATE TIME CARDIAC CAPILLARY

RATE REFILL
Sept. 16, 2019 3:00 pm 91 1-2 Secs
 6:00 pm 88 1-2 Secs
10:00 pm 87 1-2 Secs

The table represent the temperature of patient M.J during her

hospitalization. Her cardiac rate or pulse rate is normal (60-1000 and
her capillary refill is also normal (less than 3 secs.)

9. NUTRITIONAL STATUS:

The patient’s food is being served in the hospital. There is no change

of appetite during the hospitalization and health deviation. There is
no also dietary restricted reported or noted by the patient. The
patient also is able to swallow her food and medications, and able
to eat it without any assists of others.

10. ELIMINATION STATUS:

The patient verbalized that she didn’t yet excrete stool but urinated
thrice during the 3:00pm-11:00pm shift. The patient claims absence
of urinary incontinence and diarrhea.

11. SLEEP, REST AND COMFORT STATUS:

The patient verbalized that normally she sleeps 8-9 hours in a day.
Her sleep duration now was 6-7 hours. She claims that she is
comfortable with her sleep but being distracted when her baby is
crying or a nurse would monitor her.

12. FLUIDS AND ELECTROLITES STATUS:

The patient usually drinks 5-6 glasses of water a day and claims that
she urinates regularly. The patient denies the feeling of thirst and her
skin turgor is normal.

13. INTEGUMENTARY STATUS:

The patient’s skin color is brown with a skin turgor of 1-2 seconds.
There are no wounds noted and reported, there is no also odorous
secretions or oily secretions.