1.

SOCIAL STATUS

Findings Norms Analysis

Mr. GG is a 38 years old The ability to interact successfully with people The patient’s life is
male, born on February 26, 1984. and within environment of which each person is in a good and
He works as a call center agent and healthy relationship
a part, to develop and maintain intimacy with
is married. He is living in Tarlac with his family
City, Tarlac with his family. He is a significant others and to develop respect and because of the
father of 2 children. On admission, tolerance for those with different opinion and support in each
the patient wife verbalized that Mr. other’s problems.
beliefs are necessary determinant for a person’s
GG is socially close and actively
interacts with his family. Their social state. The ability to achieve balance
house is made of cement with between work and leisure time is also a needed
electricity and water supply. The
factor. A person’s belief about education,
motorcycle means transportation.
She stated that their family is employment and home influence personal
supportive as they share each satisfaction and relationship with others (Kozier
other’s challenges to ease and Erb’s 2015)
everyone’s life. His family is
generally healthy.

2. MENTAL STATUS

GLASCOW COMA SCALE

Date GSC BREAKDOWN INTERPRETATION

 SCORE

October 10, 2021 3/15 Eye Opening 1, No response

Verbal Response 1, No response
Motor Response 1 No response

October 11, 2021 5/15 Eye Opening 1, No response

Verbal Response 1, No response
Motor Response 3 Abnormal flexion

October 12, 2021 8/15 Eye Opening 3, To speech

Verbal Response 2, Incomprehensive sound
Motor Response 4 Flex to withdraw from pain

Findings Norms Analysis

2.1 Level of Consciousness

On the first day of assessment, Patient should be able to correctly respond to On the 1st and 2nd
the patient was unresponsive with days, the patient
questions and should be able to evaluate and act
revealed a GCS of 3 (E1, V1, M1), was not able to
bilaterally fixed pupils, negative appropriately in situations requiring judgment. produce
corneal response. On the 2nd day, (Estes, 2014) spontaneous,
the patient was examined. His GCS coherent speech
was 5 (E1, V1, M3), with and remained
bilaterally reactive pupils, and unresponsiveness
positive corneal reflex in the left (deep coma). 3rd
eye. On the 3rd day, the patient day prior the
least response with GSC was 9 patient least
(E3, V2, M4). responded.
2.2 General Appearance and The patient has
Behavior: generalized
Patient’s movement should appear relaxed. The
unresponsiveness
On the day of admission, Mr. GG facial expression should be appropriate to the
due to traumatic
has an untidy appearance with torn content of the conversation and should be
brain injury.
clothing and bleeding caused by the symmetrical. The appropriateness and degree of
accident. He has generalized affect should vary with the topics and the
unresponsiveness. patient’s cultural norms and be reasonable or
(normal). (Estes, 2014)

2.3 Orientation: A person is commonly aware about self, others, The Patient has no
the place, date, and time and address. (Weber, response.
Mr. GG has no response .
2013)

2.4 Speech Speech should be clear and moderate pace. It no full response
should be exerted effortlessly. (Estes, 2014)
Mr. GG was not able to full
verbalize his concerns but on the
3rd day he utters inappropriate
words such as moaning

2.5 Intellectual Functioning A person should respond normally and No response

appropriately to topics discussed. Express full
Mr. GG was not able to
and free-flowing thought during the interview
respond to questions due to altered
and listen and responds with full thought (Estes,
mental status with GCS of 3/15 to
2014)
9/15

3. Emotional Status
Findings Norms Analysis

Three days on admission, Normally, the patient should have the ability to The patient
the patient had a minimal response manage stress and to express emotion emotional status
was seen by
with the least moaning sign that he appropriately. It also involves the ability to
making one sound
is in pain and he was able to move recognize, accept and express feelings and to such as moaning.
his fingers in the hand. accept one’s limitations (Berman, 2018)

4. Sensory Perception

Findings Norms Analysis

4.1 Sense of sight the patient has

bilaterally reactive
Three days on admission, The client who has a visual acuity of 20/20 is
pupils, and positive
the patient has bilaterally reactive considered to have normal visual acuity. The
corneal reflex in
pupils, and positive corneal reflex eyes must be symmetrical during the six cardinal
the left eye and
in the left eye, and there is also the gaze’s test. The sclera shod be white with some
there is also the
presence of tenderness around the small blood vessels. Papillary constriction
presence of
eyes. should occur when struck by light. (Jensen,
tenderness around
2019)
the eyes due to
retinal damage and
hemorrhage caused
by the vehicle
accident.

4.2 Sense of smell Nose must be symmetrical and along of the face. the patient
 Each nostril must be patent and recognize the breathing pattern
smell of an object (Jensen, 2019) was assisted by a
Three days on admission the mechanical
patient nose was deformed and was ventilator at 80 %
fiO2.
partially blocked, but he is still able
to breathe with a mechanical
ventilator at 80 % fiO2.

4.3 Sense of hearing Presence of

Patient should be able to repeat the words tenderness around
Three days on admission whispered from the distance of 2 feet. (Estes, the right ears,
His ears are both clean but there is 2014) asymmetrical in
appearance due to
a presence of tenderness around
accident .
the right ears, asymmetrical in
appearance, and has discoloration
was noted. Possible complaining of
ear pain.

The patient. Mouth

4.4 Sense of taste A person can identify the taste of bitter, sweet,
structures are not
and sour. (Estes, 2014)
Three days on admission The normal and he
Patient’s teeth were incomplete due inability to fully
to an accident. Using a tongue
open his mouth,
depressor, the patient’s gag reflex
was tested but an inability to move because he has
it correctly because his mouth can’t difficulty in
move direct.
opening his mouth.

4.5 Sense of touch The skin contains receptors for pain, touch, The patient was not
pressure, and temperature. Sensory signals that able to feel and
Three days on admission to
help to determine precise locations on the skin identify which area
assess the sense of touch the patient are transmitted along rapid sensory pathways of his arm was
was still in pain as evidenced by and less distance signals such as pressure or touched and
moaning during the assessment. poorly located touch are sent via slower or responded if there
sensory pathways. (Estes, 2014) are sharp or blunt
sensations.

5. Motor Stability

Findings Norms Analysis

During confinement, The patient can’t

Patient should have a smooth and well- move freely.
decreased body movement is
coordinated movement. Her hands should swing
observed due to generalized
freely on the side. A patient should have a
weakness. He obviously still in
normal gait, able to walk in smooth and steady
pain, therefore, physical activities
manner. Abnormal findings might have hand
are still not applicable.
tremors, uncoordinated movement, stiffness,
shuffling, shoulders should not be slumped
(Hinkle & Cheever, 2018)

6. Body Temperature
Findings

Date Temperature Analysis

October 10,2021 37.3 Normal

October 11,2021 37.6 degree celcius Hyperthermia

October 12,2021 37.4 Normal

 Norms Analysis

Normally axillary temperature is within 36.4 to His temperature for

37.4 centigrade (Berman et. al., 2018) the 1st and 3rd days
was within the
normal range but
the 2nd one is above
the normal range it
was resulted in
hyperthermia during
the assessments
based on the
findings and norms
stated.

7. RESPIRATORY STATUS

Findings

Date Respiratory Rate Analysis

October 10,2021 28 cpm Tachypnea

October 11,2021 22 cpm Normal

October 12,2021 20 cpm Normal

Date Oxygen saturation Analysis

October 10,2021 89 % Hypoxemia

October 11,2021 90 % Hypoxemia

October 12,2021 96 % Normal

Norms Analysis
 A normal respiratory rate ranges from 12–20 Upon the
CPM. Breathing does not require noticeable initial assessment
effort. (Kozier and Erb’s 2015). Normal oxygen during the 1st and
saturation on the other hand ranges from 95% to 2nd day of
100 %. (HIncle and Cheever,2018 ) confinement, the
patient's GG is
slightly elevated
(tachypnea). On the
3rd day of
confinement, his
respiratory was
improved and
normalized, and on
the other hand, his
oxygen saturation
was not normal on
the 1st and 2nd
day of confinement
and it can lead to
hypoxemia but on
the 3rd day, it was
normalized. .

8. Circulatory Status

Findings

Date Pulse Rate Analysis

October 10,2021 49 bpm Bradycardia

October 11,2021 67 bpm Normal

October 12,2021 64 bpm Normal

Date Blood Pressure Analysis

October 10,2021 190 /100 mmHg Hypertension

October 11,2021 140 /90 mmHg Hypertension

October 12,2021 130/90 mmHg Hypertension

Date Capillary Refill time Analysis

October 10,2021 2 seconds Normal

October 11,2021 2 seconds Normal

October 12,2021 2 seconds Normal

Norms Analysis

Normal cardiac rate for an adult is 60-100 bpm During

while the normal blood pressure is 120/80 confinement, the
mmHg. Blach test was performed and the 1st, 2nd, and 3rd
capillary refill is less than 2 seconds and is day of Blood
normal e after it returned within normal state in Pressure
1-2 seconds . ( Berman et. Al, 2018 ) assessment are
above the normal
range considered
hypertension.
Capillary Refill
assessments 1st,
2nd, and 3rd days
were normal. Mr.
GG was
bradycardic, with
his lowest heart
rate recorded at 49
bpm on the 1st day,
but the following
day it was
normalized.

9. Nutritional Status
 Parameter Computation Norms Analysis

Height: 5’4 Weight (kg) / Underweight Normal

[height(m)] ^2
Weight: 55 kg = <18.5

BMI: 20.8
Normal weight
= 18. 5 – 24.9

Overweight
= 25 – 29.9

Obesity
= >30
(Berman et, al.,
2018)

Findings Norms Analysis

According to the Wife of Normal eating pattern is considered to be at least Based on the wife
Mr. GG. The wife stated that his three times a day depending on the metabolic of Mr. GG. The
husband usually consumes 3 meals demands and needs of the patient. Fluid intake eating pattern of
and 8 glasses of water a day. Bread should be 8-10 glasses per day (Monahan, 2017) Mr. GG was
and coffee were his usual breakfast normal before the
while rice, vegetables, and confinement but on
sometimes meat or fish for his admission, his
lunch and dinner. The wife added eating pattern was
also that his husband Mr. GG affected and it will
During snack time his husband change his diet
loves to eat bread or junk foods at such as nasogastric
work and his husband also tube feeding.
consumes alcohol occasionally and Normal BMI
he does not smoke. During
confinement, the patient's
Nutritional Status or Diet was
affected because the patient is still
in low grade in GCS a physician
ordered a nasogastric tube feeding
to bypasses the mouth and
esophagus of Mr. GG to deliver
liquid nutrition directly to the
stomach. His BMI is normal.

10. Elimination Status

Date Urine Output( Urine Output( cc/day) Analysis

cc/hr)

October 10,2021 32 cc 768 cc Normal

October 11,2021 34 cc 816 cc Normal

October 12,2021 32 cc 768 cc Normal

Findings Norms Analysis

 According to the patient The patients urine
Normal bowel movement of a person must be 1 output is normal
wife, Mr. GG defecates once a day,
to 2 times a day. A normal stool is brown in with supported
every morning. He urinates nine
color and well formed, urine is clear to catheter, defecation
times a day, however during is altered due to
yellowish in color. (Kozier and Erb’s, 2015) decreased GI
confinement, he has an indwelling
motility
folly catheter and is having trouble
defecating because of his
conditions. The patient's Urine
Output ( cc/hr and cc/day ) was
normal.

11. Reproductive Status

Findings Norms Analysis

The patient was Patient has normal

The penile shaft and glans penis, Penile skin reproductive status.
circumcised. His genitalia was
intact, appears slightly wrinkled and varies in
symmetrical and no tenderness was
color as widely as other body skin Foreskin
noted. The glans had no lesion,
easily retractable from the glans penis. Urethral
redness, or swelling. The shaft skin
meatus is pink and slit like in appearance and
is normal. No discharge was noted
Positioned at the tip of the penis. (Kozier and
Erb’s, 2016)

12. Sleep-Rest Pattern

Findings Norms Analysis

 Prior to the admission. The The patient’s sleep
An individual sleep for about 7-9 hours a day pattern is normal
patient wife stated that his husband
and takes a rest using some of activities that will prior to admission,
usually sleeps at least 8 hours,
help you to relax including reading, watching with 8 hours of
uninterrupted daily. He sleeps at sleep each day. He
television and others. Sleep refers to altered has adequate sleep
10:00 PM and wakes up at 6:00
consciousness with generation general showing and rest. However,
AM every day. After work, he rests
of physiologic process while rest refers to during
for an hour before taking his confinement, he
relaxation and calmness, both mental and
dinner. However during experienced a
physical (Estes, 2014) disturbance in his
confinement because of his
sleeping pattern
condition, patients usually can't brought by the
open their eyes voluntarily. associated
symptoms.

13. State of Skin Appendages

Findings Norms Analysis

Skin surfaces should not be tender, and the skin The patient has
On assessment, there is
is dry with a minimum of perspiration. Skin impaired skin
evident bleeding and bruising from
temperature should be warm and equal integrity that is
the wound and near the location
bilaterally, hands and feet maybe slightly cooler evidenced by
wound such as around the eyes,
than the rest of the body. Skin should normally damaged frontal
ears, and nose caused by laceration
feel smooth. The skin turgor should return within bone due to TBI,
and fracture a frontal bone. He has
2-3 seconds and edema should not normally and also there is the
also a presence of redness over the
present. The skin should be free from lesions and presence of skin
cuts and scrapes all over his face
inflammations. (Jensen, 2019). abrasions such as
and upper extremities due to
lacerations, cuts,
trauma.
and scrapes that are
caused by the skin
sliding across the
ground during an
accident.

13 AREAS OF ASSESSMENT