Marquez, Crystal Queen

13 AREAS OF ASSESSMENT
 
1. PSYCHOLOGICAL
Patient X, 68-year-old female from Baguio City was admitted at Benguet General
Hospital last May 9, 2020 with chief complaints of wrist pain, trouble with balance, trouble performing
everyday tasks, hand tremors, muscle stiffness. Three months prior to admission, she experienced left
hand tremors with decreased handwriting size using the right hand (dominant). Five months prior to
admission, she experienced decreased balance and trouble with performing everyday tasks such as
buttoning of blouse and chopping vegetables
2. MENTAL AND EMOTIONAL STATUS
Patient was seen awake and not in any signs of cardiopulmonary distress. She is conversant with mild
dysphonia (slow speech) and responds appropriately to verbal and non-verbal stimuli. She is well oriented
to time, place and person. She is able to initiate limited activity and is able to show response to pain
stimuli. During the interview, she is able to express her feelings and uses clear words.

3. ENVIRONMENTAL STATUS
Patient is well oriented to the environment and is familiar with the room set-up. The home environment,
as reported, is in a bungalow type of house, lives with a dog, with 4 steps of stairs into the house with
railing, 10 steps of stairs to the basement with railing (laundry). The bathroom has a large shower/bathtub
with a non-slip mat but no railing.
4. SENSORY STATUS 
There is no known visual deficit like color blindness. She can also distinguish voice even from a
distance, loud or soft. No corrective auditory deficits. And no auditory device noted being used by the
patient. The patient is able to discriminate an odor from the other. The patient is able to discriminate
sweet, sour, salty and bitter tastes from each other. With regards to the patient’s tactile status, she was
able to determine that the patient is able to discriminate sharp and dull, light and firm touch, able to
perceive heat, cold, pain in proportion to stimulus, able to differentiate common objects by touch by
doing necessary procedure. Patient has an intact body image and there is no aberrant sensation.

5. MOTOR STATUS 
Motor strength is assessed. her movements are limited. Patient is on sitting position with slightly
limited movement. Experienced minor fall after tripping over her dog and landed on an outstretched right
hand, leading to wrist pain. That she has limited movement against gravity and some resistance. Further,
no tremors and deformities noted on both upper and lower extremities. Upper extremities are symmetrical
as well as the lower extremities. Peripheral pulses were present such as radial. No crepitus noted upon
flexion of joints.
6. NUTRITIONAL STATUS
The patient appetite is good. There is no change in the appetite in eating during the hospitalization and
health deviation. Teeth are complete without dental carries. The skin is pallor. The nails were fine and
well-trimmed. There is no culture or religious dietary restriction reported by the patient. The patient is
able to swallow in her food and medications as well. The patient denied any indigestion, vomiting. The
patient is eating orally by herself.
 Marquez, Crystal Queen

7. ELIMINATION STATUS
The patient eliminates in a toilet bowl once a day. The stool is usually brownish and semi solid. She drinks
water to aid her elimination. There is change in her output. she verbalized that she frequently urinates during
her stay at the hospital. he urinated 1-2 times during my shift. he usually consumes 5-6 or more glasses of
water per day. The patient claimed absence of special problem like urinary and bowel retention, urinary
incontinence and diarrhea.

8. FLUID AND ELECTROLYTE STATUS 

The patient usually drinks 5-6 glasses only of water daily and urinates regularly. The patient denies the
feeling of thirst. Her skin turgor is normal and she has moist mouth and mucous membranes. The
patient’s capillary refill is 1-2 seconds. 

9. CIRCULATORY STATUS
The pulse rate during the shift is 90 beats per minute which is in the normal range. The pulse was strong
with regular rhythm. With regards to emotional stress and physical activity, the pulse rate increases. The
patient’s blood pressure is 120/70 which indicate normal.

10. RESPIRATORY STATUS  

Her is respiratory rate is 24 breaths per minute with no use of accessory muscles. There are no abnormal
breath sounds heard. The patient’s lip’s color is pinkish but slightly dry along with her nails. 

11. TEMPERATURE STATUS  

Patient’s axillary temperatures is 37.8 C, per axillary upon the initial vital signs taking. The
ward is adequately ventilated. The patient, as well, had used only one blanket, with clothes made of
cotton not greatly affecting the client’s temperature status
12. INTEGUMENTARY STATUS
Her nail base is soft when palpated, with capillary refill of 1-2 seconds. Her hair is dry, evenly
distributed, no parasite infestations, and well-trimmed. her hair is thin, fine and gray. Her conjunctiva is
slightly pale, sclera is white in color. There are no wounds noted by the client. Nails and hair are well
kept.

13. COMFORT AND REST STATUS

She claims that normally she sleeps 8-10 hours in a day. And claim that she’s comfortable. she claims that
she is very comfortable with her sleep even if she is in the ward but sometimes being disturbed when
nurses have to get her vital signs or give medication.