13-AREAS-DONE

I.
PSYCHOSOCIAL AND PSYCHOLOGICAL STATUS
- Ms. X is a 72 y/o female and married. She was admitted to the surgery ward of Benguet
General Hospital because of complaints of abdominal pain. She recently had
undergone a cholecystectomy a few days ago.
- She lives with her husband and son, and currently residing at Shilan, La Trinidad,
Benguet. She is dependent on his husband and other healthcare professionals when
it comes to her health and maintains a good relationship towards her family/
significant other. The patient and her family are Roman Catholic and have no
practices or beliefs which might aHect to providing care.
II. MENTAL AND EMOTIONAL STATUS
- The patient is conscious, alert, and coherent in responding in verbal stimuli, noise,
light, touch and pain stimuli. She is oriented to time, date, and place. She is very
cooperative and responsive to the questions that were being asked to her despite
feeling pain and restlessness due to sleep disturbances “Hindi ako makatulog ng
maayos sa sakit ng sugat ko” She also reports mild anxiety related to post-operative
recovery because of disturb sleep pattern from the pain on the surgical site. The
patient looks well-kept and dresses appropriately for her age. She is able make eye
contact when being interviewed. However, irritability is observed at times because of
restlessness.
III. ENVIRONMENTAL STATUS
- The patient is aware that she is admitted to the surgery ward of the hospital. The room
is well-lit, well-ventilated with big windows, clean, has enough space, and is
comfortable for the patient’s recovery. There are no environmental hazards, and the
setup allows for ease of care. There is an accessible bed side table provided to place
food and other essentials such as personal hygiene supplies, food, and infant care
items.
IV. SENSORY STATUS
a. VISUAL STATUS
o The patient uses reading glasses. Pupils are equally round and reactive to light
and accommodation. The sclera is white in color and the palpebral
conjunctive appears pink.
b. AUDITORY STATUS
o There are no hearing issues, and no auditory devices noted. No lesions or
discharges in both ears. She can hear normal conversations clearly, can
distinguish voices from a distance on both ears, loud and soft. No problem in
cranial nerves VIII.
c. OLFACTORY STATUS
o There are no unusual sensations noted. The patient has symmetrical,
proportionate nose with no lesions. Her nasal turbinate is pink and moist. She
can distinguish odors from another.
d. GUSTATORY STATUS
o There are no unusual sensations noted. Her lips and mouth are moderately
moist. She can taste and smell food without diHiculty and can distinguish
diHerent tastes from each other.
e. TACTILE STATUS
o The patient can perceive heat and cold, light and firm tough, and pain
sensations as she rates her pain on her surgical site as 7/10. Patient has intact
body image and there is no aberrant sensation.
V. MOTOR STATUS
o Although the patient experiences mild pain, she is ambulatory but requires
assistance in performing activities of daily living. The patient can move and
can move all her joints slowly and carefully. No prosthetic device was noted,
and all extremities are intact. She verbalized that her and husband and son
could assist her whenever she needs something.
VI. NUTRITIONAL STATUS
o Patient is on SD. She claims she has no allergies with food. The patient’s food
is being served in the hospital, modified for her fast and full recovery. The
patient’s appetite is good. There is no change in the appetite in eating during
the hospitalization. She can swallow her food and medications as well. The
patient denied any indigestion and vomiting. The patient is eating orally with
the assistance of her s/o
VII. ELIMINATION STATUS
o The patient eliminates at least once a day in a toilet bowl. The stool is usually
brownish and semi solid. She drinks water to aid her elimination. The patient
reports no diHiculty and pain when urinating, with normal output and urinated
2x during my shift. The patient claimed absence of special problem like urinary
and bowel retention, urinary incontinence and diarrhea.
VIII. FLUID AND ELECTROLYTE STATUS

o The patient usually consumes 5-6 glasses of water daily and urinates regularly.
She has an ongoing IVF of PNSS 1L regulated at 27-28 gtts/min. The patient
denies feeling of thirst. Her skin turgor is normal and has moist mouth and
mucous membranes. The patient’s skin turgor is less than seconds. No signs
of dehydration noted.
IX. CIRCULATORY STATUS

o The patient’s pulse rate ranges from 85-89 bpm. The pulse was strong with
regular rhythm. The blood pressure was high throughout the shift as the
patient is hypertensive, and is currently taking Amlodipine OD for
maintenance, while the capillary refill is less than 2 seconds throughout my
shift.
Date Time BP PR CAPILLARY INTERPRETATION
REFILL
2 PM 140/90 85 <1-2 NORMAL
11-24-24 6 PM 140/80 89 seconds NORMAL
10 PM 130/80 87 NORMAL
X. RESPIRATORY STATUS
o The patient does not utilize any accessory muscles to aid in breathing. No
abnormal breath sounds heard during auscultation. Lips are pink and moist,
while the nails are pink. Respiratory rate ranges from 15-19 breaths per
minute, while o2 sat remains above 95%, which are both normal.
Date Time RR SPO2 INTERPRETATION

11-24-24 2 PM 15 97% NORMAL
6 PM 18 98% NORMAL
10 PM 19 98% NORMAL
XI. THERMOREGULATORY STATUS

o Patient’s axillary temperature remains stable and normal throughout the
shift. There are no signs of profuse sweating or perspiration.
Date Time Temperature Interpretation

11-24-24 2 PM 37 C NORMAL
6 PM 36.5 C NORMAL
10 PM 36.8 C NORMAL
XII. INTEGUMENTARY STATUS

o Skin remains intact with good skin turgor at less than 2 seconds, no pressure
sores are present. The surgical wound is clean and dry, with a dressing in place
and sometimes felt painful. Skin color is appropriate; light to fair skin, and no
rashes, cyanosis, or jaundice observed. Nails are kept short by the patient.
There are no odorous secretions or oily secretions.
XIII. SLEEP, REST AND COMFORT STATUS

o The patient stated that she normally sleeps 6-8 hours in a day. She claims that
she has diHiculty sleeping and unable to sleep comfortably because of the
acute pain felt on the surgical site. From 6-8 hours, now she only sleeps for
about 4-5 hours.

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I.

PSYCHOSOCIAL AND PSYCHOLOGICAL STATUS

II. MENTAL AND EMOTIONAL STATUS

III. ENVIRONMENTAL STATUS

VII. ELIMINATION STATUS

VIII. FLUID AND ELECTROLYTE STATUS

IX. CIRCULATORY STATUS

Date Time RR SPO2 INTERPRETATION

XI. THERMOREGULATORY STATUS

Date Time Temperature Interpretation

XII. INTEGUMENTARY STATUS

XIII. SLEEP, REST AND COMFORT STATUS

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