13 Areas of Assessment I. Social Status Demographic Data Mr.

E is a 25 year old male, born on April 27, 1986 via NSVD by a hilot. He is the youngest of the 3 siblings. The family resides in Igbaras, Iloilo. He is still studying at University of Iloilo PHINMA taking up Bachelor of Science in Nursing.

Socio-Economic Factor Mr. E belongs in a nuclear family, Roman Catholic and a student. His father is a retired employee of Universal Distillery Company and his mother is a housewife with a family income of 20,000 pesos per month which according to Mr. E is enough to meet their basic needs. He has a sister and a brother which have a family already.

Environmental Factor Mr. E resides in a 2 storey medium size house with a 5 stairs going up to the second floor without railings, made up of concrete with 4 rooms and 1 bathroom with good ventilation. The house is located in a residential area. According to Mr. E they are buying their water for drinking and motor pump is their source of water for washing, bathing and laundry purposes. Their excreta disposal is water sealed. The family of Mr. E owns a pet dog with a regular vaccination of anti-rabies.

Erick Ericksons Psychosocial Theory Based on Ericksons psychosocial theory Mr. E a young adult is classified under intimacy vs. isolation which explains that most important event are love relationships no matter how successful a person are. He is not developmentally complete until he is capable of intimacy on the other hand, an individual who has not yet developed a sense of identity usually will fear a committed relationship and may repeat to isolation. In Mr. Es case, he had 3 relationships but now he chooses to be single and focus himself with his family and his studies.

II. Mental Status Mr. E is conscious and coherent, oriented to person, place and time. He is a college student, able to maintain eye to eye contact. He is open and approachable and is able to converse with the student nurse.

During Assessment Mr. E was able to share past experiences about his childhood and past relationship showing that his long term memories are still intact.

III.Emotional Status According to Mr. E, he is very cheerful, funny and has a sense of humour. Mr. E is close with his family and if ever he has a problem he opens it to his parents and siblings. Mr. E is a Roman Catholic, he went to church and attend the mass every Sunday this implies to him that he have faith in God and trust his life to Him. He is friendly and has lots of friends in their place.

IV. Sensory Perception Vision In assessing the vision, patient is instructed to look straight to observe the general appearance of his eyes. Eyes are almond in shape, rises are black in color, and scleras are whitish in color, eyebrows and eyelashes are equally distributed. His conjunctiva is pale and moist. Patient is also instructed to follow the direction of a finger with his eyes following six cardinal positions, and his eyes were able to move in full range of motion and in all directions. With the use of a penlight pupils are assessed, Pupils are equally round and reactive to light accommodation. The patient does not use eyeglasses or contact lenses. Visual acuity is assessed by asking the patient to read the word written in a piece of paper with a font size of 12 about 3 feet away from him using the right eye first then left eye and then both eyes.

Smell Clients nose has no deviation in terms of shape and size, nose is pointed and no discharges were seen during assessment, according to the patient, he doesnt have any history of sinus infection or epistaxis. Before the next procedure, permission was asked to the patient to do another test, using a peeled apple and the skin of an orange, without the patients knowledge, I ask him to identify the two samples by smelling. After smelling he correctly identified the two fruits. Test shows that there are no abnormalities or obstructions were identified in the sense of smell.

Hearing
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General appearance of Mr. Es ears were parallel, symmetrically proportional to the size of head, bean shaped, firm cartilage and with a presence of cerumen. In assessing the hearing acuity of the patient, Mr. E is instructed to repeat the words that will be whispered at a distance of two feet away on the left ear first, then right ear after the test, he was able to repeat the whispered words, another test by the use of the beeping sound of our electronic thermometer at a distance of 4 feet away and still he was able to hear the sound.

Taste Mr. Es lips were moist and symmetrical in shape; tongue in pinkish color, no presence of tooth decay, but there is a presence of tooth cavities, no dentures and has 4 teeth loss; 2 at the upper portion and 2 at the lower portion of the teeth, no signs of gingivitis, buccal area are moist. I assess using a tongue depressor. To assess her sense of taste, patient is asked to do some test. He was asked to taste a pinch of sugar and a pinch of iodized salt without knowing the two samples are. After the test Mr. E identified the two samples correctly.

Touch In assessing Mr. Es sense of touch, he was asked to close his eyes, a cotton ball was stroke to the back of her neck, then using another cotton ball, I poured an alcohol on it and rubbed it on the same area, and he stated that he felt a sensation of wet and cold on his skin. Using the case of BP apparatus which is rough in texture and the medical kit which is smooth in texture, the patient is asked to touch the two materials and ask the texture while blindfolded. After the test, he correctly identified the difference of two materials.

V. Motor Ability Patient is asked to perform R.O.M. exercises on the upper and lower extremities. He was asked to raise both his arms. He performed it with ease and freely moves without any difficulty. He can bend and straightened her elbows and extend and spread fingers. He performed it with ease with the muscle grade of 5+ which is normal. According to Mr. E he was able to exercise such as jogging and weight lifting if there is no class and if he has time. No inflammation, tenderness and deformity upon palpation of joints.

VI. Temperature Date Time Temperature Location

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36.9C May 17, 2011 3pm Axilla

Mr. E is afebrile and temperature is at 37.1C taken at right axilla.

VII.

Respiratory Status Date May 17, 2011 Time 3pm RR in Cycle per minute 18

His chest expansion was symmetrical with ease during respiration. Rhythm and respiration pattern are regular. He has an effective airway clearance and effective breathing pattern which provide adequate gas exchange and results to a good level of consciousness. Lungs were auscultated for adventitious breath sounds, after auscultation, no adventitious breath sounds were heard. No masses, lumps and tenderness. No supraclavicular or suprasternal retractions were seen during inspiration. VIII. Circulatory Status Date May 17, 2011 Time 3pm PR in Beats per minute 84

Pulse is regular in rate and rhythm taken at radial pulse, his capillary refill is within 1 to 2 seconds taken at right forefinger, pulse scale is 2+ which is easily palpable. Nailbeds and palms are pinkish in color and no presence of edema.

Blood Pressure Date May 17, 2011 Time 3pm BP 120/80 mmHg

Taken at her brachial artery, negative for peripheral edema.

IX. Nutritional Status Mr. E stated Kung sa school karne gid sud-an ko pirme, pero sa balay gulay kag sabaw.He drinks about 2 liters of water a day and a cup of cereal drink for breakfast. He has a good appetite and dont have any special diet. He is a non-smoker and occasional alcoholic drinker maximum of two bottles of beer. No scars, lesions and masses upon inspection and palpation of the abdomen. During auscultation 15 bowel sounds per minute were heard this implies audible and normal bowel sounds.
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Patients BMI 57.5 kg 1.57m2 = 23.37 (normal)

X. Elimination Status Mr. E stated that he defecates once a day every morning before taking a bath with a semi-solid consistency without difficulty. He urinates 8 times a day approximately 60cc per urination according to Mr. Es statement, urine output of 480cc a day. Urine is sometimes amber or straw in color.

XI. Reproductive System According to Mr. E he had his circumcision when he was 11 years old.

XII. Physical Rest and Comfort Mr. E. sleeps 8 hours a day before going to sleep he take a sponge bath and never fails to always say a prayer before going to sleep. He sleeps at around 9pm during weekdays and 11pm during weekends. He uses 5 pillows, one at his head and 2 on each side. He takes a bath everyday he uses shampoo and soap for bathing, after bathing he apply lotion in his skin and uses deodorant. XIII. Skin Mr. E has good skin turgor, no presence of tattoo, no bed sore, and no skin lesions. Patient has a dark complexion. Patient has history of skin allergy which effect from his past medication which is cefazolin this can cause to him itchiness all over the body and narrowing of airways, he also undergone appendectomy which leaves a 5 stitches scar within the right iliac region according to the patient. State of Skin and Appendages

Hair During assessment there was no dandruff seen, no lice and ticks, patient has short straight hair.

Nail During assessment nails are pinkish in color, no signs of clubbing. Patient has good capillary refill which is 1 to 2 seconds.
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Breast In assessing the breast, the patient was asked to do self breast examination, drape was provided for the patient privacy. According to the patient he doesnt feel any masses and lumps in his breast. During inspection breast is flesh colored, nipples and areola is brownish in color. Lymph nodes and axillary lymph nodes are not palpable.

Extremities The patient was assessed for Homans Signs; his legs were dorsiflexed, after the test, patient did not feel any calf pain and he dont have any signs of thrombophebitis and edema in the lower extremities.

Pain No pain during assessment.

Neck Patient has no enlargement of lymph nodes nor pain or stiffness, masses and tenderness and no enlargement of thyroid gland. During auscultation no sound heard in the thyroid gland area same with carotid arteries no swishing heard upon auscultation.