ONGOING ASSESSMENT GUIDELINES I. MENTAL STATUS a. state of mental consciousness b. orientation c. intellectual capacity d.

vocabulary level

PATIENT

DAY 1

DAY 2

awake, conscious, coherent, responsive oriented to time, date, and place Expresses full and free- flowing thoughts during interview Able to understand Simple words Has an attention span Of 20-30mins Able to understand simple instructions and tasks

Awake, conscious, Responsive to verbal stimuli Oriented to time, date and place able to perceive ideas within his level of understanding can understand simple vocabulary words and knows English, Tagalog, Bisaya and Maguindanauon an attention span of 1- 15 minutes only. Follows instructions with limits

Awake, conscious, responsive to Verbal and pain stimuli Oriented to time, date and place able to perceive ideas within his level of understanding can understand simple vocabulary words and knows English, Tagalog, Bisaya and Maguindanauon an attention span of 1- 10 minutes only. Follows instructions with limits

e. attention span f. ability to understand II. STATUS OF SPECIAL SENSES a. auditory perception b. visual perception

Can hear soft and Loud sounds clearly Able to see objects Without difficulty

Can hear sounds and Understand uttered words in slow pace able to see objects near and far clearly and has no visual defects

Can hear sounds and Understand uttered words in slow pace able to see objects near and far clearly and has no visual defects

c. speech perception

Can speak the words clearly in Moderate pace Able to perceive hot, cold and warm stimuli; sensitive to touch Able to identify Scents; sensitive to odor

d. tactile perception

had difficulty in speaking but able to communicate through nodding, sign and body language, and facial expression. can perceive hot, cold and warm stimuli. He was not able to distinguished scents

had difficulty in speaking but able to communicate through nodding, sign and body language, and facial expression. can perceive hot, cold and warm stimuli. He was not able to distinguished scents

e. olfactory perception III. MOTOR ABILITY a. current mobility

Ambulatory; without assistance Erect posture; Relaxed, stable Full range of motion

able to ambulate with assistance; without bathroom privilege Quite erect; rigid

able to ambulate with assistance; without bathroom privilege Quite erect; rigid

b. posture

c. range of motion

Limited range of motion

Limited range of motion

d. muscle and nervous status

Able to flex and extend Extremities with full strength; coordinated movements none

able to flex and extend his upper and able to flex and extend his upper lower extremities; weak muscle and lower extremities ; weak strength. muscle strength. none none

e. loss of extremities

GUIDELINES IV. BODY TEMPERATURE a. ranges

PATIENT

DAY 1

DAY 2

36.5-37.5 degrees Celsius

35.9 36 degrees Celsius

36.3 36.5 degrees Celsius

V.RESPIRATORY STATUS a. character Clear breath sounds; RR 16-23cpm has mild rales on basal part of right and left lungs; 20-21 cpm has mild rales on basal part of right and left lungs; RR 20-22 cpm b. use of respiratory aids NONE c. interference with respiration NONE With 02 @ 2L/min PRN productive cough and tracheabronchial secretions on the airway With 02 @ 2L/min PRN productive cough and trachea-bronchial secretions on the airway d. abnormal respiratory opening VI. CIRCULATORY STATUS NONE With Tracheostomy With Tracheostomy

a. characteristics of arterial pulse

regular, strong and palpable arterial pulses

regular, strong and palpable radial pulse

regular, strong and palpable radial pulse

b. apical-radial pulse

60-100 bpm

74-79 bpm

83-88 bpm

c. intravenous fluids

Without IVF

IVF #9 D5LR @ KVO rate infusing well at left metacarpal vein.

IVF #9 D5LR @ KVO rate infusing well at left metacarpal vein.

VII. NUTRITIONAL STATUS a. condition of buccal cavity b. digestion of food Moist, pinkish, no lesions moist buccal cavity, with protruded tongue. Able to masticate and Swallow the food served c. weight 52-68 kg cannot masticate and swallow the food and fluids served 38kg (malnourished) moist buccal cavity, with protruded tongue. cannot masticate and swallow the food and fluids served 38kg (malnourished)

VIII. ELIMINATION STATUS a. bowel Able to defecate at least once a day Able to urinate 3-5 times a day none not able to defecate not able to defecate

b. bladder c. abnormalities IX. MALE REPRODUCTIVE STATUS a. age of circumcision b. penile discharges X. STATE OF SKIN AND APPENDAGES a. skin

urinates 3 times during our shift none

urinates 4 times during our shift none

9-12 years old none

9 years old none

9 years old none

b. hair c. nails XI. STATE OF PHYSICAL REST AND COMFORT a. sleep/rest pattern b. presence of pain/discomfort c. use of supportive aids XII. EMOTIONAL STATUS a. emotional reaction b. body image c. ability to relate with others

Smooth, good skin turgor, brown skin complexion, poor no lesions, no rashes equal skin turgor, and presence of skin pigment ruptured mass on his left lateral face with purulent pus. Soft, equally distributed, no Soft, not equally distributed, parasites seen no parasites seen Pinkish nails, well trimmed, Pinkish nails, not wellCRT of 1-2 secs trimmed, CRT of 2-3 secs Able to sleep 6-8 hours a day none Use of pillows, blankets, good ventilation Able to express feelings of anger, sadness, happiness Good body image; high selfesteem Able to socialize with others Able to sleep 5-6 hours a day Discomfort on left lateral face mass Use of pillows, blankets, with room air

brown skin complexion, poor skin turgor, and presence of ruptured mass on his left lateral face with purulent pus. Soft, not equally distributed, no parasites seen Pinkish nails, not welltrimmed, CRT of 2-3 secs Able to sleep 5-6 hours a day Pain on left lateral face mass with pain scale of 7/10 Use of pillows, blankets, with room air

Able to express sadness and Able to express sadness and pain due to his condition pain due to his condition Low self-esteem Low self-esteem Able to socialize but with limited communication Able to socialize but with limited communication