A. Functional Assessment Functional Assessment Guidelines I. MENTAL STATUS Normal Assessment a.

State of mental Alert, conscious, The patient consciousness b. Orientation and coherent Aware time c. of conscious and coherent self. The patient

is

,alert is

Others, place and oriented to time, place and persons to and around him Intellectual Expresses full and Able free thoughts interview d. level Vocabulary Explains accurately flowing comprehend

capacity

during understand health teaching of NOD and student nurse The patient can speak in dialect, Ilocano, Ilonggo and Tagalog. and Patient has a long about 30 minutes can

e. Attention Span

Listens thoughts

responds with full attention span of to one hour to Correctly answers The patient questions understand instructions II.STATUS SPECIAL SENSES b. perception c. OF a. addressed to him Auditory Can hear clearly The patient can on both ears hear clearly on can both ears Visual Can read as far as The patient 5 meters Speech Can speak clearly

f.

Ability

understand

perception

see things even if its far from him The patient can

perception d. Tactile Can perception e. Olfactory deep touch Can odor III.MOTOR MOBILITY b. Posture a. Current Mobility

speak clearly determine The patient can and light differentiate light to deep touch determine The patient can distonguish

different scents Ambulatory at all The patient is times ambulatory at all can times Can stand straight The patient and erect posture

stand without any

supportive device c. Range of joint Has good range of The patient can motion motion flex and extend upper and lower d. Muscle and Strong strength, coordinated movements. extremities well muscle Moderate muscle strength, coordinated movements, edematous e. IV.BODY TEMPERATURE V.RESPIRATORY STATUS Loss of None 36.5- 37.5 c Regular spontaneous, 12-20 cpm b. Use of None on lower extremities. None 36.6 c and The patient has a respiratory rate of noted auscultation None upon

Nerve Status

extremities Ranges a. Character

respiratory rate of 35 cpm wheezes

respiratory aid

c.

Interference None

None None

with respiration d. Abnormal None respiratory opening VI.CIRCULATORY a. Characteristics Strong,palpable, STATUS of arterial pulse b. Apical pulse regular Synchronize strong pulses c. Intravenous None of Has lesions an

Patient has strong, palpable but rapid

pulse and Patient audible

has pulse

upon auscultation None intact With pink oral

fluid VII.NUTRITIONAL a. Condition STATUS buccal cavity

gums without any mucosa;

smooth

texture of gums; using dentures; no

b. food

digestion

dental carries of Consume all food Patient has good served appetite and can consume all food served 159lbs Able to defecate once per day; with soft non watery stool. Voiding freely,30- Can urinate 10 x a 50 cc of urine per day 30-50 cc per hour None hour Pain urination, urine.

IIX.ELIMINATION STATUS

c. Weight a. Bowel

Once a day

b. Bladder

c. Abnormalities

upon with

yellowish color of

IX.STATE OF SKIN AND APPENDAGES

a. skin

Has complexion skin smooth.

fair The

patient

is

with warm to touch with and with wrinkles. Skil has visible scars on his arms

relatively poor skin turgor

b. Hair c. Nails

Evenly distributed Convex fingernails well trimmed

and legs. Thinning

and

graying on scalp;. shape Patient has and convex shaped of nails, not trimmed sleep 6-8

X.STATE OF PHYSICAL REST AND COMFORT

a. sleep pattern

nails Sleep 6 8 hours Can a day

hours; naps at 2030 mins. Pain in coughing and disturbance in

b. pain

Presence

of None and

discomfort c. Use supportive aids XI.EMOTIONAL STATUS a.

sleeping of Use of pillows and Uses 2 pillows and blankets in 1 blanket, cool

sleeping environment Emotional Verbalizes positive Expresses coping mechanisms Good body image feelings verbally Has good body

Reaction b. Body image

c. Ability to relate Response to others appropriately discuss topics

image Respond to appropriately discussed to topics

and can relate to significant others