GUIDELINES

NORMAL
ASSESSMENT

Mental status
State of Mental
Consciousness
Conscious,
coherent and able
to follow instructions

Conscious, coherent and able to follow
instructions

Orientation Oriented to place
events and time
Patient is oriented to people around and
knows that she is in the hospital. She
knows the day and time. She remembers
her birthdate.
Attention span Responds on
questions being
asked, able to recall
past, present events
Responds on questions being asked and
can comprehend but with short attention
span. She communicates with an eye to
eye contact but not with the entire
conversation.
Ability to understand Speaks well at
spoken language
with organization
and can be clearly
understood
Speaks in Tagalog with organization and
can be clearly understood. She can also
able to speak in Visayan language AEB
talking to her husband. She can able to
understand hand gripping when asked.
Status of Special Senses
Auditory perception Attentive and
comprehend
instructions with
long attention span
Attentive; can hear well in both ears by
responding to questions being
asked/heard. Reacts on the news being
heard on the television about 3 meters
away from her.
Visual perception See objects without
the use of aid,
glasses while
reading
Sees objects with the use of reading glass.
AEB reading text messages 1 foot away
from her. Sometimes complaints blurry
vision
Speech perception Speaks clearly that
can be easily
understood
Speaks in a soft voice which can clearly be
understood.
Tactile perception sensitive to warm
and cold sensation;
able to feel pain or
touch
The patient can able to feel the coldness
of air the air-conditioned room. The patient
can able to feel the warmth of food being
served to her. Patient felt pain when thumb
are pinched.
Olfactory perception could distinguish
from foul smelling
and frequent smell
The patient can smell the food being
served to her
Motor Ability
Current mobility ambulatory without
assistance
Ambulatory with little assistance when
going to the comfort room to urinate.
Posture normal curvature of Normal curvature of the spine is observed
GUIDELINES
NORMAL
ASSESSMENT

spine, with erect
body posture in
standing and sitting
position
while the patient is in standing and sitting
position.
Range of Motion able to perform
unlimited active and
passive range of
motion on both
upper and lower
extremities
Able to perform limited range of motion on
the upper extremities such as moving the
arm while reaching for a glass of water.
Able to move the lower extremities since
the patient can walk going to the CR. Head
can turn left to right and up-down direction.
Upper body can turn to both sides.
Muscle and nervous
status
hard tonic, strong
muscle strength,
coordinated muscle
movement and well
developed muscle
mass
Fair muscle strength and coordinated
muscle movement. Grip at both hands is
moderate. Leg movement is moderate.
Average weakness with muscle strength
no.3 (active motion against gravity)

Loss of extremities None No loss of extremities
Temperature 36.5
o
C - 37.5
o
C 37.8
o
C taken @ 7am-3pm shift and
36.6
o
C taken @ 3-11pm shift
Respiratory Status
Character regular, deep
breathing with no
abnormal sounds;
RR ranges 16-22
cpm
Clear breath sounds with respiratory rate
of 22 cpm
Use of respiratory
aids
no respiratory aids
used
No respiratory aid used
Interfere with
respiration
No obstacle
interfering
respiration, no nasal
discharge
No interference with respiration
Abnormal
respiratory opening
No abnormal
respiratory opening
No abnormal respiratory opening
Circulatory Status
Characteristics of
arterial pulse
strong, palpable
arterial pulse ranges
60 - 100 bpm
Strong, palpable pulse at 1188 bpm.

Apical-radial pulse Synchronized
radical pulse ranges
from 60-100 bpm
Synchronized radial-apical pulse with 118
bpm
Blood pressure 110/70 mmHg-
130/90 mmHg
150/100mmHg
Pulse pressure Bounding within Bounding within normal range. Pulse
GUIDELINES
NORMAL
ASSESSMENT

normal range pressure is strong, palpable and within
normal range.
Intravenous fluid Without IVF PNSS 1L @60 cc/hr
Nutritional Status
Condition of bucal
cavity
teeth are intact,
without
inflammation and
lesion
Teeth are intact without inflammation and
lesion. No dentures. Mouth are dry without
inflammation
Digestion of food Digest any food and
masticate at ease
The patient is able to consume all food
being served. Urge to eat shortly after
meal. Digest any food and masticate it at
ease. Tends to drink more water due to
thirst
Diet Diet as tolerated Full diabetic diet with 1520 cal. 2 grams
NaCl, <200 mg cholesterol, <7% saturated
fat, low purine
divide by 3 meals and 3 snacks
Weight BMI (18.6-24.9) 50.7 kgs
Height 150 cm.
Elimination Status
Bowel Regular movement
without difficulties,
defecates 1-2x a
day
The patient has defecated once without
difficulties and abnormalities. Soft in
consistency. Brown in color.
Bladder Voiding freely;
urinate 5-10x a day
Voiding freely with yellow color and clear
consistency. Verbalizes frequent urination
specially at night. Urinates 6x with urine
output of 750 cc within 8 hours
Female Reproductive Status
Age of menarche 12 years old 11 years old
Pattern of menses Able to consume 5-
6 pads in 4-5 days
Regular pattern of menses as mentioned
by the patient and admitted that she is
already menopause at age 54 years
Status of skin and appendages
Skin Good skin turgor,
uniform skin color
Dry skin, uniform in color with light skin
complexion, capillary refill test of less than
2 seconds;
Hair hair is well
distributed, no
infestations
Hair is well distributed and neatly cut, no
infestations. Slightly wavy with some gray
colored hair and slightly short in boys cut
Nails clean, well trimmed
nails
Well trimmed, clean and uncolored nails
State of physical rest and comfort
Sleep/rest pattern sleeps at least 8 Sleeps at least 4 hours d/t medications,
GUIDELINES
NORMAL
ASSESSMENT

hours and not
disturbed
visitors and vital signs monitoring. Nap is
being observed and noted in between vital
signs monitoring.

Presence of
discomfort
presence of pain is
unusual
Presence of discomfort is felt such
dizziness, itchy skin, frequent urination,
fatigue and drowsiness.
Emotional Status
Emotional reaction expresses feelings Carefully chooses words to convey
feelings and ideas. States in a weak voice
that she worries about little things more
now than she used to and tends to be
irritated sometimes.
Body image good body image
with normal body
alignment
Decreased body image. Client rates own
health as 7 on a scale of 1 (worst) to 10
(best). She described it as 9 as compared
to five years ago. Sees health deterioration
as normal aging process.

Ability to relate
others
approachable and
friendly
Approachable and friendly. Describes
relationship with other members as
friendly. Has casual relationship with
neighbors. Visits the community center to
attend church functions.
Nursing Diagnosis 1. Decreased cardiac output r/t decrease ventricular filling
(preload) secondary to hypertension
2. Hyperglycemia r/t Diabetes Mellitus 2 AEB increased
sugar level
3. Risk for fall r/t benign paroxysmal positional vertigo
(BPPV) AEB dizziness