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BSN-NBA2
13 AREAS OF ASSESSMENT
A. Psychosocial Status
Patient X is a 60 years old female, who is currently living with her children and
middle-class Filipino female. She does not have work due to old age but she actually now
spends most of the time transferring from house to house of her children so that she could
visit her grandchildren and have a fun time with them. When observed during the shift,
the patient was seen to smile often during eye contact and interaction.
Patient X is conscious and conversant. She is oriented to time and date. Her
husband actually died 10 years ago. Due to that experience, it has allowed her to draw
upon and rely on it to be able to aid her with any problems she is currently dealing with,
internally and externally. She counts on her family and friends to help her “talk through”
stress periods. Overall, she is a strong mother who can manage her problems with the
C. Environmental Status
The GYNE ward at the hospital was neat and tidy. The patient was provided with
a single bed with side rails and with a bed side table and chair. It has a common comfort
room for the whole ward which is around 6 -7 meters away from her bed. The bed is 2
meters away from the next bed. The windows in the ward were opened every day to
Patient was cooperative, oriented and alert. Also, upon arrival, she maintains eye
contact with the student nurses. She is appropriately groomed and dressed and was able
to talk or answer when asked about her condition and well-being after the procedure.
Visual Status
Patient wears Eye Glass with a grade of 250 on both eyes and she has denied
discharge, pruritus, pain, visual disturbances although she has weakened eye vision due
to old age. Upon inspection, eyebrows showed no unexplained hair loss. Lashes curved
outward away from the eyes and are distributed evenly along the lid margins. Eyelids
opened and closed completely, with spontaneous blinking. Eye shape is almond-shaped,
symmetrical and in parallel alignment. Bulbar conjunctiva was transparent with small
blood vessels visible. Sclera is clear, smooth, white and without exudate, lesions, or
foreign bodies.
In assessing for the visual fields, static and kinetic confrontation tests were
performed. With the static confrontation, patient accurately reported number of fingers
presented in all four quadrants. Also, with the kinetic confrontation test, patient saw the
fingers at approximately the same time as the student nurse. To test for the extraocular
muscle movements, the corneal light reflex, the unilateral cover test and the cardinal
fields of gaze were done. When doing the corneal light reflex (hirschberg) test, light
reflection was in exactly the same spot in both eyes. Also, pupils were noted as black,
equally round and both reacted to light. Pupils constricted (accommodation) and eyes
crossed (converge). When cover test was done, patient’s gaze was steady and fixed. Eyes
moved smoothly and symmetrically in all nine cardinal fields of gazes. Patient was able
Upon inspection, patient’s ears were symmetrical, equal in size and fully formed.
Using an otoscope, the canal has fine hairs with some intact cerumen lining the wall skin,
no discharge and no visible lesions noted on the patient’s ear. The tympanic membrane
was also intact and translucent with greyish color. Patient claimed that she can hear and
distinguish voices clearly and can repeat words correctly when whisper test was done.
Patient’s lips are moist, pinkish in color, symmetrical with no signs of ulceration.
Patient has whitish to slightly yellowish teeth and pinkish gums. Buccal mucosa and soft
and hard palates were pinkish moist, with no inflammation, ulceration, swelling, or
lesions. Tongue is pinkish located at the middle, moist and symmetrical. Patient claims
that she does not experience difficulty of swallowing. When asked to say “ah”, the uvula
was noted to rise symmetrically. Patient is fluent in speaking in English and Tagalog and
Tactile
Different visual tests were done to assess for the normalcy of the sensation. When
the patient was asked to close her eyes and applied light touch to the skin with a cotton
swab, she was able to correctly identify light touch. When assessing the intact of point
localization, the patient was asked to close her eyes. Using a finger, the patient was
gently touched on the hands, lower arms and abdomen. She was able to correctly identify
the location bilaterally. When stereognosis test was done, patient was able to distinguish
objects placed on her palms with her eyes closed. Also, graphesthesia test was performed
and the patient correctly identified the number traced on her palm.
E. Motor Status
The patient was able to move her upper extremities and lower extremities but she
was showing signs of protective behavior towards her abdomen due to the TAHBSO
procedure done. She was able to walk and sit with assistance. When assessing the muscle
strength, the result shows that there is an active movement against full resistance which
was graded as 5 in the right upper, left upper but the right lower and left lower
extremities were graded as 3 with movement possible against gravity, but not against
5 5
/ /
5 5
3 3
/ /
5 5
F. Nutritional Status
Prior to admission, patient claimed that she takes meals three times a day.
According to the patient, during the admission she does not have appetite to eat but she
drinks water for hydration. After the surgical procedure, the patient was not able to eat
G. Elimination Status
Prior to admission patient claimed that she urinates at least 4-5 times a day and
defecates once a day. During the shift, she urinated more than ten times and described it
Before the procedure she was hooked with the D5LRS but after the procedure it
was removed. She is able to drink 1500-2000 mL of a water per day. Normally, she
consumes 2366 ml of water daily but after the surgery she only consumes 500 ml of
Patient’s respiratory rate was 18-20 cycles per minute. This means that she had
normal respiration during her admission. She had clear breath sounds. She also claimed
J. Circulatory Status
The patient’s cardiac rate ranged from 61-85 beats per minute which is in the
normal range. Regular pulses were also noted. Patient’s blood pressure was taken at the
K. Temperature Status
The body temperature of the patient ranged from 36.3℃ - 36.9℃ taken through
the forehead using infrared thermometer, no febrile episode was noted during the shift.
L. Integumentary Status
Upon assessment of her skin, she had a tan brown complexion. She has cold
clammy hands with poor skin turgor and capillary refill of 4 seconds. The skin is slightly
dry. Her nails were pinkish in color and well-trimmed. Her hair is thick and dyed with
brown color.
The patient stated that prior to admission, she usually sleeps around 6-7 hours
starting from 10 pm because she watches her teleseye first and wakes up 4 in the morning
for she has to prepare for their breakfast. During admission the client claimed that her
sleeping pattern was changed due to environmental factors and to the pain she was