13 Areas of Assessment I. Psycosocial Status a. General Social Status Patient X is a 56 feet.

He is currently residing in a simple house in baculugan Sur Buguias, Benguet Province. He is a Roman catholic in faith. He has a strong faith in God and believes that prayers is very helpful especially with his condition. b. Family/Peer Group Status Patient X belongs in a nuclear family. He is the youngest son of the 9 siblings. He supports her wife and her husband. c. Social Development Status Patient X is a 55 year old male, born on August 08, 1956 via NSD by a midwife in benguet. He is a father of 4 children with 2 sons and 2 daughters. Two of her sons stopped going to school due to financial problem. Her wife stays at home

Erick Ericksons Psychosocial Theory Based on Ericksons psychosocial theory, patient X is in his middle-age stage. He is therefore under generativity vs. stagnation. People in this kind of stage focus in work and parenthood. They tend to create things that will make them a better person like taking care of their children and making positive changes that will benefit other people. If they will be successful in doing it, they have the sense of usefulness and accomplishment. On the other hand, people without the sense of generativity will become stagnated.

II. Mental-Status Mental Status Patient X is very approachable and responsive. He is conscious and coherent, oriented to time and date. He is a high school graduate and is able to read and write. He is able to follow instructions and able to maintain eye to eye contact. His chronological age is directly proportional to his developmental age where his focus includes financial security, career and family He is open and approachable and is able to converse with the student nurses. a.

Emotional Status Prior to hospitalization, according to patient X, he is very hard working, he loves to make conversations with their neighbours, people in school and his family. After his surgery result, he was already fearful for he dont know what will happen. Aside from the fear the he experienced, he was financially distress due to the health insurance problem. For this reason, he had to stay for few more days until her operation. After the operation, patient X became very irritable and anxious due to pain.

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III. Environmental Status a. Safety Factors Patient X is currently staying in the Thessalonians room. The room is not that well ventilated and well arranged, he cannot afford a private room that is why he shares a room with other patients. . b. Infection Control Patient X is aware of his condition, therefore, takes precautions and sanitary control in order to prevent infection. He makes sure that he always use alcohol and washes his hands before and after feeding and every time he handles materials that can create infection. c. Environmental Effects on Illness Patient X is not that comfortable in his present room , after her surgery, she became frightened. Every time he hears a knock on the door, he thinks that the medical team will perform an invasive surgery to him. For this reason, he is very frightened and anxious on the knocking and opening of the door.

IV. Sensory Perception a. Vision Status Patient X has round eyes, his irises are black in color, and scleras are whitish in color, eyebrows and eyelashes are equally distributed. His conjunctiva is not pale nor moist. b. Auditory Status General appearance of patient xs ears were parallel, symmetrically proportional to the size of the head, bean shaped and firm cartilage. He is able to hear words properly and can distinguish voices from near and far distance. No signs of deafness was observed.

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Glustatory Status Patient xs lips were moist and symmetrical in shape; tongue is pinkish in color, no presence of tooth decay and no teeth loss. He can distinguish sweet, sour, salty and bitter food. Olfactory Status There are no abnormalities and no obstruction in the sense of smell of patient X. Clients nose has no deviation in terms of shape and size, nose is pointed and no discharges were seen during assessment. Tactile Status Patient X is able to distinguish different objects and whether they are hot or cold, smooth or rough. He is now experiencing acute pain due to the invasive surgery that was done to him. Language Perception & Formation Patient x can interact well with people. He is able to speak and pronounce words clearly. He is able to read and write.

V. Motor Status a. Medical Restriction on Activity Before his surgery, he is able to go to the comfort by himself. After his surgery, he has Indwelling Folley Catheter. b. Muscoloskeletal status There are no presences of deformity seen in his extremities and in proper symmetry between left and right side of each extremity. Patient can bend his legs and arms with limited range of motion and needs assistance when standing and going to the comfort room.

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Mobility Patient x stays mostly on bed and needs assistance in doing her activities of daily living due to the surgery that she went through.

VI. Nutritional Status Patient x prefers to eat more on vegetable food rather than meat. He usually eat 3 times a day before hospitalization. During his stay in the hospital, he was in soft diet. Prior and after his surgery, he was in NPO. Before his surgery, he was in IVF of BMRS and D5NR. After his surgery, he is now in IVF of D5LRS. He is not talking any oral medications, but instead parenteral medications.

VII. Elimination Status Patient X stated that prior to surgery, he defecates 1-2 times with a little amount of semi-solid consistency and brownish in color with difficulty. He urinates 5 times a day approximately 50-100 cc per urination. After surgery, the patient has IFC connected to urine bag with amber color urine. VIII. Fluid and Electrolytes Patient X stated that she usually drink 1-2L of water every day. He currently has an IVF of D5LRS. IX. Circulatory Status Date/ Time November 21, 2011 10 am Blood Pressure 110/80 76 cpm Pulse Rate

2 pm November 22, 2011 10 am 2 pm X. Respiratory Status Date/ Time November 21, 2011 10 am 2 pm November 22, 2011 10am 2 pm

140/90 120/80 mm/Hg 110/80 mm/Hg

74cpm 83cpm 76 cpm

Respiratory Status 22 bpm 18 bpm 18 bpm 19 bpm

XI. Temperature Status Date/ Time November 21, 2011 10 am 2 pm November 22, 2011 10 am 2 pm

Temperature in Celcius 36.8 36.5 37.2 36.9

XII. Integumentary Status Prior to operation, patient X have good skin turgor with no history of skin allergy, no presence of tattoo, no bed sore, no skin lesions. Patient has a fair complexion. After the surgery, the clients skin turned into a slight pale in but with good skin turgor, and no presence of bedsore were seen. No lice were seen, and patient has thick, oily, wavy hair. Prior to operation, Nails are pinkish in color and no signs of clubbing. XIII. Comfort and Rest Status Before hospitalization, Patient X usually sleeps 9-10 hours around 8pm-5am. During hospitalization, he complains of not being able to sleep properly sometimes having only 2-3 hours of sleep. Patient is uncomfortable due to pain in her operative site.