13 Areas Of Assessment
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13 Areas of Assessment
Social Status Pt. X is female, 15 y.o currently residing at J.C AquinShe is Born Again in faith. In the ward, her mother accompanied her. She is approachable whenever she is called for attention. Emotional Status Pt. X has a good support by her family especially with her mother. Her mother supervised all her need. She states that she is very blessed and happy because she had her family. Cognitive/Mental Status She is very responsive upon interaction. She is well oriented about the time, date and place where she is right now. Body Temperature Pt. was febrile with body temp. of 39C. Circulatory Status Pt. pulse rate is 85 bpm taken from the radial pulse. Her BP is 100/70 mmHg. Respiratory Status She has a cycle of 22 cpm without any signs of irregularities in breathing. Nutritional Status Before Hospitalization Pt. X usually prefers to eat meat especially process meats. She eats 3x a day but sometimes skip meals. She also loves to eat junk foods and also spicy and sour foods. During Hospitalization She was on soft diet due to her condition. Elimination Pattern Before Hospitalization She usually defecates once or twice a day and urinates 3-5 times a day. During Hospitalization As of now she defecates once a day and urinates 2-3 times a day. Reproductive Status Pt. X is a female and had her first menarch when she was 12 years old with regular cycles.
Perception and Coordination Status All of her senses were functioning. She is very responsive and coherent upon interaction. Rest and Sleep Patterns Before Hospitalization She usually sleeps 6-8 hr around 10pm-6am and could have a naps and rest at daytimes. During Hospitalization As of now she sleeps for only 4-6hrs with intervals and could still have naps and rest at daytimes. State of Skin and Appearance She had a long curly hair with fine skin with no lesions. She is well groomed and has a good skin turgor. State of Mobility Pt. X stays mostly on bed, and could only walks when she is going to the bathroom. She is in CBR with TP.
Social Status Pt. X is female, 15 y.o currently residing at J.C AquinShe is Born Again in faith. In the ward, her mother accompanied her. She is approachable whenever she is called for attention. Emotional Status Pt. X has a good support by her family especially with her mother. Her mother supervised all her need. She states that she is very blessed and happy because she had her family. Cognitive/Mental Status She is very responsive upon interaction. She is well oriented about the time, date and place where she is right now. Body Temperature Pt. was febrile with body temp. of 39C. Circulatory Status Pt. pulse rate is 85 bpm taken from the radial pulse. Her BP is 100/70 mmHg. Respiratory Status She has a cycle of 22 cpm without any signs of irregularities in breathing. Nutritional Status Before Hospitalization Pt. X usually prefers to eat meat especially process meats. She eats 3x a day but sometimes skip meals. She also loves to eat junk foods and also spicy and sour foods. During Hospitalization She was on soft diet due to her condition. Elimination Pattern Before Hospitalization She usually defecates once or twice a day and urinates 3-5 times a day. During Hospitalization As of now she defecates once a day and urinates 2-3 times a day. Reproductive Status Pt. X is a female and had her first menarch when she was 12 years old with regular cycles.
Perception and Coordination Status All of her senses were functioning. She is very responsive and coherent upon interaction. Rest and Sleep Patterns Before Hospitalization She usually sleeps 6-8 hr around 10pm-6am and could have a naps and rest at daytimes. During Hospitalization As of now she sleeps for only 4-6hrs with intervals and could still have naps and rest at daytimes. State of Skin and Appearance She had a long curly hair with fine skin with no lesions. She is well groomed and has a good skin turgor. State of Mobility Pt. X stays mostly on bed, and could only walks when she is going to the bathroom. She is in CBR with TP.
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