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CANONIZADO, RICA MAE

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

grandchildren in their house at Olongapo City. Her cultural affiliation is self-described as

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.

B. Mental and Emotional Status

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

help of her loved ones.

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

properly ventilate the room.


D. Sensory Status

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

to move eyes without difficulty or pain.


Auditory Status

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.

Gustatory Speech and Formulation

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

was able to understand what was said.

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

resistance by the examiner.

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

anything as there were diet restrictions given to her.

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

as brownish color and she didn’t defecate during the shift.

H. Fluid and Electrolytes Status

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

water every day.


I. Respiratory Status

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

that she does not have any discomfort when breathing.

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

foot and it ranged from 110/80 mmHg to 160/70mmHg.

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.

Perspiration was present during daytime.

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.

M. Sleep and Rest Pattern Status

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

experiencing. She wakes up every 2 hours because she needs to go urinate.