13 Areas Of Assessment

13 areas of assessment I. Social Status Patient x is a 23 year old male client, born on September 14, 1985and is currently residing at Lapaz, Tarlac. He lives with his parents(how many they are? What is the occupation of patient x’s parents? His occupation?) (what does patient x always do? during his hospitalization, was he supported?) Norms: Social status includes family relationships that state the patient’s support system in time of stress and in time of need. It meets a fundamental human need for social ties, making life less stressful and social support buffers the negative effects of stress, thus indicating indirectly contributing to good health outcomes. (fundamentals of nursing, Barbara Kozier, seventh edition) Analysis: (Does the patient has a good relationship to his family? Does the support coming from his parents helps him cope up and buffer the negative effects of stress? Do they able to sustain the meds of patient x?) II. Mental Status The patient is able to state correctly the place and time during his assessment. (does he remember his hospitalizations before? ) the patient is able to read words shown to him( i.e. words in the chart like name, address, age). He is able to write his name without difficulty and he could differentiate the objects shown to him (i.e. differentiating banana from an apple.)

Norms: The patient should be oriented to time and place, can identify past and recent memories and should be able to verbalize concrete messages. The patient’s ability to read and write should match his educational level. The patient should be able to respond to questions and identify all the objects presented to him. The patient should be able to evaluate and act appropriately in situation. (estez health assessment and physical examination third edition.) Analysis: The patient is oriented to time and place, could identify long-term and short-term memories and able to deliver concrete messages. His ability to read and write matches his educational level. The patient was also able to respond in questions asked to him and was able to identify objects presented to him. The patient was able to evaluate and act appropriately in situations requiring his judgment. III. Emotional Status Patient X will take few seconds sometimes to answer a question regarding his ailment. He said he is a bit nervous regarding his condition and wants to be well and go home as possible and told us that he is thinking about the medication if where his family will seek to buy those for him. Norms: Young adult is a time of separation and independence from the family and of new commitments, responsibilities, and accountability in social, work, and home relationships and roles. (Health Assessment and Physical Examination, Mary Ellen Zator Estez) Analysis: Client is aware regarding his condition. His hospitalization merely affected his status.

IV. Sensory Perception •

Sense of sight

The client is asked to sit facing the snellen’s chart at the distance of 20 feet occluding the other eye. The client had 20/20 visual acuity on the right eye, the same with the left. With the use of penlight the following were observed:  Pupils constrict when struck by light  Patient’s eyes are symmetrical and round  Sclera is white in color  Eyes are symmetrical in moving. Norms: The client who has a visual acuity of 20/20 is considered to have normal visual acuity. The eyes must be symmetrical during the six cardinal gazes test. The sclera should be white with some small blood vessels. Papillary constriction should occur when struck by light. (Health Assessment and Physical Examination, Mary Ellen Zator Estez) Analysis: With the given data, the patient’s visual acuity, extraocular muscle movements and papillary response are normal. •

Sense of taste

Client was examined using variety of food which tastes salty, bitter, sweet and sour. Patient was able to differentiate each taste.

Norms: Taste is intact in the posterior one third of the tongue. (Health Assessment and Physical Examination, Mary Ellen Zator Estez) Analysis: Client’s sense of taste is normal. •

Sense of hearing

For the auditory assessment, the voice whisper test was used. Words were whispered and the patient was instructed to repeat the words that were whispered. The procedure was then repeated to the other ear. Norms: For the auditory acuity, the patient should be able to repeat the whispered words from a distance of two feet. (health assessment and physical examination, mary ellen zator estez) Analysis: Based on the given data, patient’s auditory acuity is normal. •

Sense of smell

The patient’s nose is in the midline of the face and is symmetrical, there were absence of any obstructions or secretions. We provided common foods such as coffee. Norms: Nose must be symmetrical and along of the face. Each nostril must be patent and recognize the smell of an object. (health assessment and physical examination, mary ellen zator estez)

Analysis: Client was able to recognize the given food. Airway is clear. Patient x’s smell sense is normal. •

Tactile sensitivity

In the examination of the touch sensation of the patient, he was instructed to close his eyes and tell what he feels when he was going to be pricked on his palm. The patient responded and stated that the pricking was painful. Using a small test tube with warm water pat on his skin for few seconds, he was able to identify that it’s hot. Norms: The skin contains receptors for pain, touch, pressure and temperature. Sensory signals are transmitted along rapid sensory pathways, and less distinct signals such as pressure of localized touch are sent via slower sensory pathways. (Health Assessment and Physical Examination, Mary Ellen Zator Estez) Analysis: The patient’s sensory transmission functions well as manifested by the data presented. V. Motor Stability and Gait Patient X’s gait was assessed using the heel to toe method. He was able to stand on his own and balance himself during the assessment. He didn’t complain any difficulty when moving from one place to another and states that he likes to move rather than sit and stay in bed. He has no difficulty moving in between positions. Assessment of the range of motion of the patient was done through instructions which include the ability of the patient to bend his shoulder apart. He can also move his shoulder laterally and medially as well as rotate his shoulder in the same manner. He can

also bend his elbows and farther apart or rotate it laterally to face upward and extending beyond the neutral position. The patient can also flex and extend his knees of his ankles and feet, or tilting his feet inward and moving it toward and away the midline of his body. His neck is symmetrical with his head in central position. Movements through full range of motion can be done without any discomfort. Norms: In standing position, the torso and head are upright. The head is midline and perpendicular to the horizontal line of the shoulders and the pelvis. The shoulders and hips are level, symmetry of the scapulae and iliac crests. The arms are freely from the shoulders. The feet are aligned and the toes point forward. Walking initiated in one smooth rhythmic fashion. The foot is lifted 2.5 to 5 cm to the floor ad propelled 30 to 45 cm forward in a straight path. The patient remains erect and balanced during all stages of gait. The patient should be able to transfer easily to various positions. There should be absence of discomfort during range of motion exercise. (health assessment and physical examination, mary ellen zator estez) Analysis: Patient X’s gait and balance are coordinated and his movements and actions are normal for his age. Also, he has no difficulty and can perform ROM exercise with ease. VI. Body Temperature Date Assessed 8/07/09 8/07/09

Norms:

Time 6 p.m 10 p.m

Temperature 36.5°C/axilla 37.2°C/axilla

A normal range of body temperature is 36.6-37 Celsius via axilla for 6 minutes (Daniels 2004). Analysis: Upon assessing Patient X’s body temperature, the data given above indicates that he possess a normal body temperature. VII. Respiratory Status Date Assessed 8/07/09 8/07/09

Time 6 p.m 10 p.m

Respiratory Rate 18 cpm 16 cpm

When Patient X is auscultated, his breath sounds are normal, no cough and difficulty in breathing is noted. Norms: Respiratory quality or character refers to those aspects of breathing that are different from normal. Normal breathing sounds are: a) Vesicular- soft, low pitched, heard over periphery of lungs. b) Broncho-vesicular- soft, medium-pitched, heard over major bronchi. c) Bronchial- loud, high pitched, heard over trachea. (G & N notes-Gregory N. Yalma, M.D.) A normal respiratory rate ranges from 12–20 cpm. (Kozier, Fundamentals of Nursing, 7th Edition). Analysis: Patient X had a normal breath sounds. The patient’s respiratory rate is in normal range.

VIII. Circulatory Status

Date Assessed 8/07/09 8/07/09

Time 6 p.m 10 p.m

Heart Rate 63 bpm 62 bpm

Blood Pressure 110/80 mmHg 110/70 mmHg

During the assessment of his capillary refill, his nail beds returned to its original color after 4 seconds. Norms: The normal cardiac rate or pulse rate is 60 -100 bpm. The average blood pressure of a healthy adult is 120/80 mmHg. The normal capillary refill test is 2-3 seconds and upon capillary refill test was done and it returns to normal state within 2-3 seconds (Kozier, Fundamentals of Nursing, 7th edition). Analysis: The data given above shows that Patient X’s pulse rate is in normal range. He also had a normal blood pressure. His capillary refill is slow. IX. Nutritional Status Before the hospitalization, Patient X usually prefer to eat meat especially processed meats. He eats 3x a day but sometimes skip his lunch. Prior to admission, the patient’s diet was comprised mainly of vegetables, fish, poultry and rice. He drinks 1000 to 1500 mL of water daily. He had minimal food intake because he stated that he couldn’t taste the food he eats. Norms: According to the Health Asian Diet Pyramid, there should be a daily intake of rice, grains, bread, fruit and vegetables; optional daily for fish, shellfish, and dairy products; weekly for sweets, eggs and poultry, and monthly for meat. There should be an increase intake of a wide variety of fruits and vegetables. Include in the diet foods higher in vitamins C and E, and omega-3 fatty acid rich foods. (www.webmd.com)

Analysis: Patient X had minimal food intake during admission to the hospital due to his loss of appetite. X. Elimination Status Before hospitalization, Patient X usually defecate one to two a day and voids 4 times a day. Since admission, Patient X defecated 6 to 8 times per day with a characteristic of watery stool. He voids 3 times in one day and described it as amber in color and had a strong odor with an output of 700mL. He also vomited 3 times during his stay in the hospital. Norms: Normal bowel movement of a person must be 1 to 2 times a day and voiding in 3 to 4 times a day with an output of 1200 to 1500 ml a day. A normal stool is brown in color and well formed, urine is clear to yellowish in color. (Fundamentals of Nursing, kozier, 2007) Analysis: With regards to Patient X’s elimination status, it appears that the patient is having a diarrhea and some signs of dehydration as evidenced by the decrease in the amount of the urine output. XI. Reproductive Status Patient X verbalized that he had been circumcised but refused to have his reproductive system assessed.

XII. Sleep-Rest Pattern Patient X before his admission stated that he sleeps at least 8 hours a day. He usually sleeps at 10pm and wakes at 6pm for daily household tasks. Sometimes, he takes

a nap at the afternoon. But prior to his hospitalization, his sleeping pattern has been changed he stated due to environmental factors. Norms: Adults’ average amount of sleep per day is 7 to 8 hours. (wikipedia.org) XIII. State of Skin and Appendages As we assessed the client, there is IV site at his right hand. There is absence of infiltration or phlebitis. Client was pinched at the abdomen; we observed that the skin returns to its original state slowly. His skin is warm and non tender. Skin feels smooth, even and firm. Patient X’s hair is black with light even distribution on the scalp, eyebrows and eyelashes. Norms: When the skin is pinched then released, it should return to its original contour rapidly. Hair varies from dark to pale blonde based on the amount of melanin present. The body is covered in vellus hair. Terminal hair is found in the eyebrows, eyelashes, and scalp, and in the axilla and pubic areas after puberty. Native Americans, Asians, and those from the Pacific Rim may have a light distribution of hair. Skin is dry with minimum perspiration. Skin surfaces should be non tender. It should normally feel smooth, even and firm. (Health Assessment and Physical Examination, Mary Ellen Zator Estez) Analysis: Patient X has decreased skin turgor, due to lack of fluid in the tissues. He has normal texture, distribution, color and temperature. Localized or systemic tenderness is absent.