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    13 Areas of Assessment 1. Psychosocial Status

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    Cheska Ysabelle
    The document provides a 13-point assessment of a 33-year-old postnatal patient. It summarizes her psychosocial status as a single mother living in Benguet. Her mental status examination found her oriented and able to communicate clearly. The patient was comfortable in her postnatal ward environment. Sensory exams found intact vision, smell, taste, and touch. Motor function was limited but symmetrical. Vital signs including temperature, respiration, pulse, and blood pressure were stable over three days of monitoring. Nutritional status was adequate though skin was slightly dry. Elimination was normal. Sleep was undisturbed. Fluids and electrolytes were balanced without dehydration signs. Skin was generally healthy with good turgor

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    13 Areas of Assessment 1. Psychosocial Status

    Uploaded by

    Cheska Ysabelle
    2K views3 pages
    The document provides a 13-point assessment of a 33-year-old postnatal patient. It summarizes her psychosocial status as a single mother living in Benguet. Her mental status examination found her oriented and able to communicate clearly. The patient was comfortable in her postnatal ward environment. Sensory exams found intact vision, smell, taste, and touch. Motor function was limited but symmetrical. Vital signs including temperature, respiration, pulse, and blood pressure were stable over three days of monitoring. Nutritional status was adequate though skin was slightly dry. Elimination was normal. Sleep was undisturbed. Fluids and electrolytes were balanced without dehydration signs. Skin was generally healthy with good turgor

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    13 Areas of Assessment

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    The document provides a 13-point assessment of a 33-year-old postnatal patient. It summarizes her psychosocial status as a single mother living in Benguet. Her mental status examination found her oriented and able to communicate clearly. The patient was comfortable in her postnatal ward environment. Sensory exams found intact vision, smell, taste, and touch. Motor function was limited but symmetrical. Vital signs including temperature, respiration, pulse, and blood pressure were stable over three days of monitoring. Nutritional status was adequate though skin was slightly dry. Elimination was normal. Sleep was undisturbed. Fluids and electrolytes were balanced without dehydration signs. Skin was generally healthy with good turgor

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    2K views3 pages

    13 Areas of Assessment 1. Psychosocial Status

    Uploaded by

    Cheska Ysabelle
    The document provides a 13-point assessment of a 33-year-old postnatal patient. It summarizes her psychosocial status as a single mother living in Benguet. Her mental status examination found her oriented and able to communicate clearly. The patient was comfortable in her postnatal ward environment. Sensory exams found intact vision, smell, taste, and touch. Motor function was limited but symmetrical. Vital signs including temperature, respiration, pulse, and blood pressure were stable over three days of monitoring. Nutritional status was adequate though skin was slightly dry. Elimination was normal. Sleep was undisturbed. Fluids and electrolytes were balanced without dehydration signs. Skin was generally healthy with good turgor

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    13 Areas of Assessment

    1. Psychosocial Status

    - Patient is a 33 year old single mother currently residing in Benguet.

    2. Mental and Emotional Status

    - Patient is seen awake and not in any sign of distress. She is conversational, coherent and responds
    appropriately to verbal and non-verbal stimuli. She is well oriented to time, place and person. She is able
    to initiate limited activity and is able to show response to pain stimuli. During the interview, she is able
    to express her feelings and uses clear words. Concerning her child, she expresses her joy at the
    successful delivery.

    3. Environmental Status

    - Patient is well oriented to the environment and is familiar with the room set-up. The patient is in
    postnatal ward. It is adequately ventilated. No unnecessary noise was noted. It is also spacious. The floor
    was also well maintained and non-slippery. No scatter rugs were seen. Other than that, patient has no
    complaints of uneasiness or discomfort concerning his environment.

    4. Sensory Status

    a) Visual Status - the sclera is white in colour and the palpebral conjunctiva appears pink. She is
    able to move eyes without tenderness, pain or difficulty.
    b) Auditory - Upon assessment, no visible lumps or lesions are noted.
    c) Olfactory Status - The patient has intact sense of smell as manifested by the ability to distinguish
    familiar odour such as coffee during assessment. No epistaxis was noted. Nose was seen to be
    symmetrical, proportionate and no lesions seen.
    d) Gustatory Status - Patient is not using dentures. There is no difficulty in masticating and
    swallowing as verbalized. He has intact gag reflex.
    e) Tactile Status - Facial sensations are also intact and symmetrical on both sides. She is able to
    perceived heat, cold and pain sensations.

    5. Motor Status

    - Patient is on fowler’s position. She has muscle strength of 3/5 on both upper and lower extremities,
    which means that she has limited movement against gravity and some resistance. Further, no tremors
    and deformities noted on both upper and lower extremities. Upper extremities are symmetrical as well
    as the lower extremities. Peripheral pulses were present such as radial. No crepitus noted upon flexion
    of joints. Extremities are warm to touch.

    6. Thermoregulatory Status
    Date Time Temperature

    7am 36.3 °C

    April 05, 2018 10am 36.4 °C

    2pm 36.6 °C

    7am 36.0 °C

    April 06, 2018 10am 36.4 °C

    2pm 36.0 °C

    7am 36.0 °C

    April 07, 2018 10am 36.5 °C

    2pm 36.2 °C

    7. Respiratory Status

    Date Time RR SPO2

    7am 21 cpm 93 %

    January 05, 2015 10am 23 cpm 95 %

    2pm 24 cpm 98 %

    7am 22 cpm 92 %

    January06, 2015 10am 20 cpm 93 %

    2pm 19 cpm 95 %

    7am 20 cpm 96 %

    January 07, 2015 10am 18 cpm 95 %

    2pm 17 cpm 97 %

    8. Circulatory Status
    Date Time CR Capillary

    January 05, 2015 7am 98 bpm

    10am 94 bpm 2-3 seconds

    2pm 95 bpm

    January 06, 2015 7am 89 bpm

    10am 88 bpm 2-3 seconds

    2pm 90 bpm

    7am 97 bpm

    January 07, 2015 10am 97 bpm 1-2 seconds

    2pm 95 bpm

    9. Nutritional Status

    -The patient’s skin appears to be slightly dry; she has a good skin turgor that returns in 1-2 seconds. Hair
    is noted to be terminal in the scalp, eyelashes and eyebrows with no parasite infestation. Patient has
    slightly dry lips and oral mucosa.

    10. Elimination Status

    - Patient’s frequency of urination is estimated to be 3 times per shift at approximately 750 cc. she uses
    the bathroom with assistance and privacy is observed. No pain was reported to be felt during urination.

    11. Sleep, Rest and Comfort Status

    - The patient sleeps comfortably, there are no signs of sleep disturbance.

    12. Fluids and Electrolytes Status

    - Patient is able to consume 350 cc of water. She has a good skin turgor; skin and hair are slightly dry.
    Patient’s skin is brownish and has pinkish nail beds. No signs of dehydration noted as well as edema
    formation.

    13. Integumentary Status

    - Patient’s skin is dry generally white, without pigmentations, no pallor, jaundice or cyanosis. She has
    good skin turgor. Her nail base is soft when palpated, with capillary refill of 1-2 seconds. Her hairs are
    slightly dry, evenly distributed, no parasite infestations, and well-trimmed.

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