13 Areas Of Assessment (tomas Claudio Memorial College)

13 Areas of Assessment I. Social Status Demographic Data Mrs. Y is a 39 year old female, Born on August 1, 1970 via NSD by a midwife. She is the eldest of the 11 siblings. The Family resides in Navotas Cardona, Rizal. She has 5 offspring, 2 are working already while the remaining are still studying. Socio-Economic Factor Mrs. Y belongs in an extended family, Roman Catholic and a fish vendor, while her husband works as a construction worker both are high school undergraduate with a family income of 11,000.00 pesos per month which according to Mrs. Y are just enough to meet their basic needs. Environmental Factor Mrs. Y resides in a medium size house made up of concrete with 3 rooms and 2 large windows which resulted to good ventilation. The house is located in a congested area. Artesian well is their source of water. Their excreta disposal is with water carriage. Erick Erickson’s Psychosocial Theory Based on Erickson’s psychosocial theory, Mrs. Y a young adult is classified under Intimacy vs. Isolation which explains that the most important event are love relationships, no matter how successful a person are, she is not developmentally complete until she 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 Mrs. Y’s case, she values her relationship with her husband. They have been married for 24 years already and still they have a good loving relationship, according to Mrs. Y, they try to solve things together to avoid fighting and they are both emotionally attached to each other during hospitalization. II. Mental Status Mrs. Y is conscious and coherent, oriented to time and date, she is a high school undergraduate and is able to read and write and follow instructions, able to maintain eye to eye contact. Her chronological age is directly proportional to her developmental age where her focus includes financial security, career and family according to Sullivan’s stages of development. She is open and approachable and is able to converse with the student nurses. During Assessment, Mrs. Y talks about her childhood memories, showing that her long term memories are still intact.

III. Emotional Status Prior to hospitalization, according to Mrs. Y, she is very cheerful, she loves to make conversations with their neighbors, sisters and her husband. During hospitalization before the operation, Mrs. Y is still very cheerful and makes some jokes during assessment. After the operation, Mrs. Y became very irritable due to pain, but still she stated that they don’t have any financial problem since her sisters and her husband are very supportive not just financially but also emotionally. This shows that they have a good relationship status with her family. IV. Sensory Perception Vision In assessing the vision, patient is instructed to look straight to observe the general appearance of her eyes. Eyes are almond in shape, irises are black in color, and scleras are whitish in color, eyebrows and eyelashes are equally distributed. Her conjunctiva is pale and moist, Patient is also instructed to follow the direction of a finger with her eyes following six cardinal positions, and her 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 her using the right eye first then left eye and then both eyes. Then test was repeated but this time it will be only 1 foot away from her using the same procedure. Different words were use written in different paper in every test. Mrs. Y read all the samples during the test. Smell Client’s nose has no deviation in terms of shape and size, nose is pointed and no discharges were seen during assessment, according to the patient, she doesn’t have any history of sinus infection or epitaxis. 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 patient’s knowledge, we ask her to identify the two samples by smelling. After smelling she correctly identified the two fruits. Test shows that there are no abnormalities or obstructions were identified in the sense of smell. Hearing General appearance of Mrs. Y’s ears were parallel, symmetrically proportional to the size of the head, bean shaped, firm cartilage and with a presence of

cerumen. In assessing the hearing acuity of the patient, Mrs. Y is instructed to repeat the words that will be whisper at a distance of two feet away on the left ear first, then right ear after the test, she 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 she was able to hear the sound. The test was repeated 3 days after the surgical procedure and the result was the same. She verbalized that she has no known auditory deficits nor ear infection history and unusual sensations like ringing or buzzing. Taste Mrs. Y’s lips were moist and symmetrical in shape; tongue is pinkish in color, no presence of tooth Decay, but there is a presence of tooth cavities, no dentures and no teeth loss, no signs of gingivitis, buccal area are moist. We assess using a tongue depressor. To assess her sense of taste, Patient is asked to do some test. She was asked to taste a pinch of sugar and a pinch of iodized salt without knowing the two samples are. After the test Mrs. Y identified the two samples correctly. Touch In assessing Mrs. Y’s sense of touch, she was asked to close her eyes, a cotton ball was stroke to the back of her neck, then using another cotton ball, we poured an alcohol on it and rubbed it on the same area, and she stated that she felt a sensation of wet and cold on her 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, she correctly identified the difference of two materials. V. Motor Ability Pre-operatively, patient is asked to perform R.O.M exercises on the upper and lower extremities. She was asked to raise both her arms. She performed it with ease and freely moves without any difficulty. She can bend and straightened her elbows and extend and spread her fingers. She performed it with ease. According to the patient, she usually has leg cramps that occur anytime of the day especially when lying in high-fowlers position. There are no presences of deformity; there are also proper symmetry between left and right side of each extremity. Post-operatively, the patient was instructed to remain flat on bed for a few hours after surgery, and then early ambulation was encouraged. Patient can bend her legs and arms with limited range of motion and needs assistance when standing and going to the comfort room. Patient Verbalized: “Sumasakit kasi yung opera ko kapag gumagalaw ako”

VI. Temperature Date September 21, 2009 September 22, 2009 September 23, 2009

Time 4pm

Temperature 36.5 C

Location Axilla

8am (pre)

36.4 C

Axilla

4pm (post) 6-2pm 4pm

37.0C 38.0 C 37.3 C

Axilla Axilla

4pm

36.8 C

Axilla

September 24, 2009

Mrs. Y’s is febrile In September 23; temperature is at 38.0 ‘C taken at Right axilla.

VII. Respiratory Status Date September 21

Time 2pm

RR in Cycle per minute 17

September 22

8am (pre) 2pm (post) 2pm 2pm

September 23 September 24

16 18 23 18

Her chest expansion was symmetrical with ease during respiration. Rhythm and respiration pattern are regular. She 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 sounds, after auscultation, no adventitious sounds were heard. No supraclavicular or suprasternal retraction were seen during inspiration VIII. Circulatory Status Date September 21 September 22

Time 2pm 8am (pre) 2pm (post) 2pm 2pm

September 23 September 24

PR in Beats per minute 70 73 75 92 76

Taken at radial pulse, her capillary refill is within 1 to 2 seconds taken at right forefinger, pulse scale is 2 + which is easily palpable. Blood Pressure Date and Time September 21 2pm September 22 8am 10:30am 10:45am 11:30am 11:45am 12:00pm 12:30pm 12:45pm 1:00pm 2:00pm September 23 6 – 2pm 2 – 10pm September 24 6 – 2pm 2 – 10pm

BP 120/80 mmHg 130/80 mmHg 100/60 110/70 100/70 120/80 120/80 120/80 110/70 120/90 140/90 130/90

mmHg mmHg mmHg mmHg mmHg mmHg mmHg mmHg mmHg mmHg

130/90 mmHg 130/90 mmHg 120/90 mmHg

Taken at her left brachial artery, negative for peripheral edema.

IX. Nutritional Status

Prior to hospitalization, Mrs. Y stated “Madalas isda ulam naming tapos konting gulay kasi nga fish vendor ako”. She drinks about 7 to 9 glasses of water a day. She has a good appetite prior to operation. Prior to surgery she is on NPO, on the second day after surgery she was on a soft diet but encourage eating nutritious food to help for her recovery. She eats lugaw, biscuit and cupcake. The patient is with ongoing IVF of BMMS 1 liter x 30gtts/min. Patient’s BMI 66.0kg 1.58m =26.58 (overweight) X. Elimination Status Mrs. Y stated that prior to surgery; she defecates once a day every morning with a semi-solid consistency without difficulty. She urinates 4 to 5 times a day approximately 50 to 70cc per urination according to Mrs. Y’s statement. Urine is amber in color. After surgery, the patient has a diaper and IFC connected to urine bag with amber color urine with a recorded urine output of 400cc with an IVF input of 700cc. The IFC was removed on her 2nd day post-operation. She only defecates on the 3rd day when she Dulcolax suppository was inserted. She had a positive flatus but negative bowel movement in the first and second day post-procedure. 1st Day Post Surgery >IFC was inserted. > (-) Bowel Movement >(+) Flatus

2nd Day Post Surgery >IFC was removed. >(-) Bowel Movement >(+) Flatus

3rd day Post Surgery >Inserted Dulcolax Suppository. >(+) Bowel Movement

XI. Reproductive System According to Mrs. Y, she had her menarche when she was 11 years old. With an OB score of G7P5 (5025). She had 2 abortions more than 3 years ago because according to Mrs. Y, she doesn’t want to have a child anymore. Abdominal Girth was measured by using a tape measure, it measured 48cm. She had no history of any surgical operations such as BTL and did not undergo Caesarian Section. She uses oral contraceptive as her contraception or family planning method. Prior to surgery, patient stated that she has vaginal bleeding with presence of blood clot consuming 3 to 4 pads a day fully soaked with a bright red in color. According to the patient her menstruation lasted 20 days that started in July of this year accompanied with menstrual cramp and sometimes low back pain, her usual menstrual period lasted 3 to 5 days. Post-operatively, the patient stated “Dati nung di pa ako naooperahan dinudugo ako at may konting buo-buo na dugo ngayon nawala na”.

XII. Physical Rest and Comfort Prior to hospitalization, Mrs. Y sleeps 4 hours a day without any routine going to sleep. She stated “Lagi akong puyat, apat na oras lang madalas ang tulog ko kasi nagtitinda ako ng isda madaling araw pa lang, tapos basta may chance matulog ay matutulog talaga ako kaso sandali lang talaga”. Post-operatively, the patient usually sleeps within 6 to 8 hours at night and wakes up during medication then she usually takes a nap at day time. Patient is uncomfortable due to pain She stated during our post-op assessment to her “pwedeng mamaya na lang, masakit talaga yung opera sa akin”. She usually lies on bed. XIII. State of skin and appendages Skin Prior to operation, Mrs. Y have good skin turgor with no history of skin allergy, no presence of tattoo, no bed sore, no skin lesions. Patient has a fair complexion. After the surgery, the client’s skin turned into a slight pale in color in the second day, temperature is warm to touch but with good skin turgor, and no presence of bedsore were seen. Hair Presences of dandruff were seen during assessment, no lice were seen, and patient has thick wavy hair. “Hindi na ako nakakapaglinis ng katawan ko, ni hindi ko magawa ang makapagayos o makapagsuklay man lang”, as verbalized by the patient

Nails Prior to operation, Nails are pinkish in color, no signs of clubbing. Breast In assessing the breast, the patient is asked to do self breast examination, drape was provided for the patient for privacy. According to the patient she didn’t feel any mass or lumps in her breast. She also stated that she didn’t have any history of bleeding and nipple tenderness. Extremities the patient was assessed for homan’s Signs; her legs was dorsiflexed, after the test, the patient did not feel any calf pain and she don’t have any signs of thrombophlebitis and edema in the lower extremities.

Pain Prior to hospitalization, the patient stated “kapag meron ako, kumikirot lagi puson ko” ➢ Severity of pain according to patient’s perception of pain is 3 to 4 (painscale of 1 to 10) ➢ Precipitating factor: Occurs during menstruation ➢ Alleviating factor: Drinking medications ➢ Related symptoms: None Post-operatively, the patient stated “Masakit yung opera ko, kumikirot talaga”. The pain occurs anytime at the abdominal area with a pain scale of 6 to 7 according to patient’s perception of pain, pain worse when moving or standing according to the patient, pain is alleviated by medication or lying on bed. Neck Prior to operation, patient has no enlarged lymph nodes nor pain or stiffness and no thyroid enlargement. After the operation, patient’s lymph nodes become palpable.

NURSING PROBLEMS The following are the nursing problems that have been established during assessment.

Acute pain related to effects of surgery as manifested by irritability ➢ Self-care deficit, Hygiene/bathing related to activity intolerance as manifested by inability to perform the most basic physical task and personal care activities ➢ Bowel incontinence related to laxative as manifested by inability to urge to defecate. ➢

NURSING CARE PLAN SUBJECTIVE “Ang sakit ng tahi, masakit talaga” -pain scale of 7/10 Objective: -Irritability -Facial grimace -limited attention span -Increased v/s (RR,BP,PR,Temp)

PLANNING -After 4 hours of NIC, patient’s feeling of pain will alleviate from pain scale of 7 to 5.

INTERVENTION INDEPENDENT --Encourage Verbalization of feelings

RATIONALE -Pain is subjective data which cannot be felt by others. -for baseline data.

-Monitor v/s -Position change and back rubs. -Encourage deep breathing exercise -Encourage activities that will divert attention like listening to music or reading magazine. -Encourage pt. to report pain as soon as possible.

-Helps to minimize pain.

-To promote relaxation -To diverts’ patients’ perception of pain.

-Timely intervention is more likely to be successful in alleviating the pain. -To prevent fatigue

-Encourage rest period.

GOAL –

Goal is met, pain has alleviated from pain scale of 7 to 5 as evidence by patient’s reaction to pain and progress of v/s after 4 hours of NIC.

-To reduce pain DEPENDENT -Administer pain reliever as prescribed such as Toradol. -To determine if COLLABORATIVE there is -Notify physician if complications and measures are find possible unsuccessful or if intervention current complaint is a necessary for the pt. significant change collaboratively with from patients past the physician. experience of pain. Nursing diagnosis: Acute Pain related to effects of surgery as manifested by irritability

Subjective “Sumasakit kasi yung opera ko kapag gumagalaw ako” Pain scale of 7 out of 10 Objective: -Slow movement -Increased RR, BP, PR -uncombed hair -presence of seborrhea

Planning After 4 hours of NIC, the patient will be able to do activities of daily living within her capabilities and patient will be able to attain good hygiene with the assistance of Significant others and nurse assigned.

Nursing Intervention Independent: > Evaluate limitations of actions and Monitor V/S

> Planned care with rest periods between activities

Rationale

> To provide baseline The patients was able to do activities of data daily living within her capabilities And attain good hygiene After 4 hours of NIC > To reduce fatigue

> Assisted patient with activities (selfcare)

> To protect patient

>Cleaning the body of the patient.

>for the purpose of relaxation and cleanliness

>provide assistance until patient is fully able to assume selfcare

>placed things within

Goal Goal met.

from injury

>lessens effort

reach like comb.

>lessens effort

Dependent: -administer pain reliever as prescribed such as toradol prior to bathing

-to reduced pain

Collaborative: >Instructed and assisted SO to clean the patient’s body with a wet towel

>Promote grooming of patient

>Stressed and performed proper hygiene and grooming to patient

Diagnosis: Self-care deficit, Hygiene/bathing related to activity intolerance as manifested by inability to perform the most basic physical task and personal care activities