SUMBAD,MARK BHEN E.

GYNECOLOGY
BSN-NBA2 MA’AM JUVY CARAME

13 AREAS OF ASSESSMENT

1. Psychological Status:
A. Patient G lives with her parents. The Religion of the
patient is UCCP (United Church of Christ). According to the
father, patient G was not yet baptized. The Father is
originally from Baguio City while the mother is from Nueva
Viscaya. Mother is working as a teacher in senior high while
the father works as a part-time driver.
B. Patient G lives with his parents in Nueva Viscaya together
with his 2 siblings and often visit his grandma in Baguio City,
father’s side. Patient G is the 2 nd child who loves to play
spinning top or known as “trumpo.”
C. Patient G is a 7-year-old boy, grade 2 student of Bayombong
Elementary School and independent with his ADL’s activity. He
speaks and understanding Tagalog Ilocano, and English.

2. Mental and Emotional Status:

A. Patient G is conscious, alert and coherent. He is very
responsive in verbal stimuli, noise, light, touch and pain
stimuli. He is oriented to current time, date and place. Able
to recall and has remote memory, able to know reasons of
hospitalization, able to respond all instructions given to him,
able to maintain eye to eye contact. Glasgow coma scale
assessment is 15/15.
B. He acts according to his age has, good perception about his
health, very cooperative and no social concern of fears were
noted, and no medicine or substance were taken to alter
emotional response. Patient G is a jolly kid as he laughs at
simple jokes and seems to be handling stress very well knowing
that he was in the hospital.

3. Environment Status:
Patient G likes to play outside their house in Nueva Viscaya
where the weather is a little warm. As verbalized by the
father, the area where they live is peaceful and away from the
city noise. Patient G plays a lot as manifested by his
 abrasions in his left elbow and middle finger on the right
hand.

4. Sensory Status:
A. Sensory: Eyes are almond in shape, black in color, sclera is
white, and eyelashes are equally distributed. Conjunctiva are
pale and moist, normal eye movement, pupils are equally round
and reactive to light and accommodation. No masses or
tenderness palpated.
B. Ears are parallel, symmetric proportional, no presence of
discharges, can distinguish voice even from a distance, loud or
soft.
C. Nose- no deviation in terms of shape, size, no discharges,
no evident pf bleeding.
D. Mouth is moist and symmetrical in shape, tongue in pinkish
color, no lesions or abrasions, presence of tooth decay.
Patient can distinguish sweet, sour, salty, and bitter taste
from each other.
E. With regards to tactile status, patient can distinguish
sharp and dull, light and firm touch. He can perceive heat,
cold, pain in proportion to stimulus and to differentiate
common objects by touch.
F. Speech of patient G is intact of speech organs, ability to
understand and initiate speech without difficulty, and ability
to read write and copy figures.

5. Motor Status:
Patient G’s movements are not limited. He can move his joints
carefully; no prosthetic device was noted present and all
extremities are intact. Patient G has a good posture, shoulders
are in symmetry, good endurance and has a good coordination and
stability upon walking. He is not using any supportive aid
canes, crutches, walkers, or wheelchairs.

6. Nutritional Status:
Patient’s food is being served in the hospital. He eats three
times a day. His breakfast is being served at 7am, lunch at
11am, while dinner is at 8pm. He prefers sweet goods, junk
foods and carbonated drinks such as coke and Pepsi. Sometimes
 there are leftover foods in his dishes. If his viand includes
vegetables such as okra and ampalaya, his appetite is
decreased. There is no change in his appetite during the
hospitalization. His skin is smooth with brownish color. There
is no culture or religious dietary restriction reported by the
mother of patient. He can swallow in his food and medication a
well. Patient is eating orally by himself. Patient G has a low
sodium and low-fat diet. Patient takes vitamin to boost his
appetite, but he won’t take it on a regular basis as verbalized
by the father.

7. Elimination Status:
Patient G still has a tea-colored urine as observed on the
urine container. Patient was able to urinate. Patient G was
given furosemide to increase urine output a day before
discharge to increase urine output. Patient has no
difficulty/pain during micturition.

8. Fluid and Electrolyte Status:

During our last day of duty, patient G drank a total 650 ml of
water with an output of 680ml from 7am-11pm combined amount
with the 7-3 shift. His skin turgor is good and has no moist
mouth and mucous membrane. Pt doesn’t drink water as much and
drinks soda instead.

9. Circulatory Status:
Pulse rate during shift is 101 bpm within normal range. The
pulse was strong with regular rhythm. Patient’s blood pressure
taken while sitting on bed is 100/70. Nail beds and palms are
pinkish in color, capillary refill is 1-2 seconds, no presence
of edema observed, heart sounds are normal, and its rhythm is
regular.

10. Respiratory Status:

His RR is 22 bpm with no use of accessory muscle. There were no
abnormal breath sounds heard. Patient’s lip color is pinkish
but slightly dry. Patient G does not smoke nor his family
 members in the household. He does not use, nor does he need
assistive devices in breathing.

11. Temperature Status:

Patient’s temperature is within 36.6-36.9degreecelsuis during
our shift which is within normal range. There is no profuse
sweating or even irritation. The environmental temperature is
cold, and patient verbalized that he feels warm. Pt doesn’t use
blanket at night as verbalized by his father.

12. Integumentary Status:

Patient G has brown skin color, good hydration. Patient G has
abrasion of the left elbow and on his middle finger on the
right hand which he got of too much playing as verbalized by
his mother. Hair are equally distributed with thick, black
hair. No presence of lice and dandruff. Nails are pinkish in
color, no presence of clubbing.

13. Comfort and Rest Status:

A. He usually sleeps 8-9 hours as verbalized by his father.
Patient G doesn’t usually use blanket at night as he feels
warm. Patient G doesn’t use any medication to fall asleep.
B. Patient G gets to sleep comfortable at night as verbalized by
father.