Anda di halaman 1dari 2

13 Areas of Assessment . I.

Psychological Status

According to Erik-eriksons 8 stages of development the client is under the Ego integrity vs. Despair (65 to death). This stage occurs during late adulthood from age 65 through the end of life. During this period of time, people reflect back on the life they have lived and come away with either a sense of fulfillment from a life well lived or a sense of regret and despair over a life misspent or the presence of despair causes life to be viewed meaningless. II. Emotional Status

Mr. X is aware of time, place and his current situation. He is 74 year old, his speech is slurred. Prior to hospitalization according to his wife, Mr. X had a sudden onset of Right sided body weakness so they sought consult at a nearby hospital. One day prior to admission, no noted improvement hence opted to transfer to BGH. During hospitalization he is irritable. III. Environmental Status

The family lived in Abatan, Buguias Benguet. Mr. X resides in a medium size house made up of concrete with 3 rooms and 2 large windows which resulted to good ventilation. Their water system is from spring. He occasionally drinks alcohol beverages. Mr. X was admitted at BGHMC (Baguio Medical Hospital Medical Center) at stroke ward with 6 beds, 3 feet near the window which result to a good ventilation. The bed of the patient has a side rails to ensured safety. IV. Sensory Status Sense of Sight

His conjunctiva is pale, and his sclera is white in color. His eyes are symmetrically and round. His eyes are positive to direct papillary and light reflex pupils. Sense of Taste

His lips were dry and symmetrically in shape. Prior to hospitalization, the client is eating through Nasogastric tube (NGT) feeding. Before and after feeding the client, suction is rendered as necessary. The client is positive (+) to equal palatal elevation and positive (+) gag reflex. Sense of Hearing

His ears were parallel , symmetrically proportional to the size of his head, bean in shape , firm cartilage and with the presence of cerumen , he has a gross equal hearing. Sense of Smell

His nose is in midline of the face and symmetrical, there were some of secretions. Prior to hospitalization the client has oxygen connected to face mask at 5lpm.

V.

Motor Status

Mr. X has a right body weakness, he cant move alone, needs assistance in changing positions, he is not comfortable with his condition, he has impaired physical mobility. He cant move his right body, good muscle noted , he had weak shoulder shrug. VI. Nutritional Status

He had a food intake through Nasogastric Tube (NGT) feeding, food given by the dietician of the hospital. VII. Elimination Status

Mr. X urinates through IFC connected to urine bag, dark amber in color at 750ml and he defecates once during our shift. VIII. Fluid and Electrolytes

Through NGT feeding he was able to drink water and take his medication after we pound and dissolved it in water. Mr. X was ordered to have an ongoing IVF of PNNS 1 L. IX. Circulatory Status

His pulse rate is ranging from 86 to 93 bpm. X. Respiratory Status

His respiratory rate is ranging from 23 to 26 per minute. Lungs were auscultated and crackles heard on both lung field. His SPO2 is ranging from 97 to 99. At times he experienced difficulty of breathing. XI. Temperature Status

His temperature is ranging from 36 degree Celsius to 36.8 degree Celcius. XII. Integumentary Status.

He has a white and little black hair, his hair is straight. He has afebrile skin. Some parts of his skin had cyanosis. XIII. Rest and Comfort.

Prior to hospitalization he sleeps 5-7 hours at night and wakes up during medication through NGT and his sleep is interrupted due to pain or to his condition.