13 Areas of Assessment 1 6 Revised
13 Areas of Assessment 1 6 Revised
13 Areas of Assessment 1 6 Revised
I. SOCIAL STATUS
Findings:
Patient DML is a 59-year-old Filipina, currently living with her husband along with her
son at San Roque, Tarlac City. According to the patient, she is very active in their
neighborhood, and she always has time to visit her daughter’s family who lives 2 km
away from their home. She also mentioned that when she is in pain or having
problems, she is sharing them with her family. With the interview conducted patient
DML is very open with her family, she always shares her thoughts and feelings.
Norms:
Social status includes family relationships that state the patient’s support system in
times of stress and in times of need. It meets a fundamental need for social ties,
making life stressful, and social support buffers the negative effects of stress, thus
indicating indirectly contributing to good health outcomes (Kozier & Erb’s, 2018).
Analysis:
Patient DML’s social status was normal and does not affect her current condition.
Level of consciousness:
Patient DML is awake and alert with both eyes open and looking directly at the
examiner, she was able to state her name when asked, and the date and month
today.
Orientation:
The student nurse asked her some detailed questions about her name, age, date,
month, where she lives, and where she is. She was able to answer them correctly.
According to her, her name is DML, 59-year-old. The date today is December 3,
2021, she lived in San Roque, Tarlac City and she was admitted to Tarlac Provincial
Hospital.
Speech:
When we conducted the interview to test the patient's speech, the patient was asked
to state 10 countries, 10 fruits, and 10 colors. She was able to state them all clearly
and the student nurse noticed that she has a crooked smile with a slight facial
drooping on the right side and a minimal slurring of speech with a low modulated
voice.
Intellectual function:
The student nurse asked her to name all of her children and her husband. She was
able to respond to the questions properly and correctly. When the student nurse
asked if she can still remember her past history, she just nods her head as an
answer.
Norms:
General appearance and behavior:
The patient should be able to stand still, have smooth and coordinated movement
(Jensen, 2019).
Level of consciousness:
The patient must be alert and awake with eyes open and looking at the examiner and
able to respond appropriately (Kelley & weber, 2018).
Orientation:
A person is normally aware of self, others, place, time, and address (Weber, 2018).
Speech:
Speech should be at a clear and moderate pace. It should be exerted effortlessly
(Jensen, 2019).
Intellectual function:
A person should respond normally and appropriately to topics discussed. Express full
and free-flowing thoughts during the interview and listen and respond with full thought
(Jensen, 2019).
Analysis:
Patient DML’s general appearance was not normal because the student nurse noticed
that she has a crooked smile with a slight facial drooping on the right side and a
minimal slurring of speech.
c) Sense of Hearing:
Auditory acuity to whispered or spoken voice was assessed to the patient, including a
watch tick test. Cerumen was visible in the ear canal of both ears. The result was,
patient, is unable to hear properly to the watch tick test and the word whispered by
the student nurse. The tympanic membrane was pearly grey in color.
d) Sense of Smell:
No signs of a lesion, swelling, or flaring on the nasal septum. The nose is uniform in
color. Sinuses were palpated and no evidence of swelling or lumps was noted, and
no pain was felt by the patient either. Patient DML was given two cups being
blindfolded, she was instructed to smell on each cup. The first cup contains coffee
while the second cup contains cinnamon bread. She was asked to identify both
substances. The patient was able to identify which is which.
V. MOTOR STABILITY
Findings:
During the assessment, patient DML show’s willingness to cooperate she was able to
move in command and was able to understand the instruction being said. When the
patient was asked to stand from the chair and walk a straight line, she was able to
walk with a stable gait. While she was walking the student nurse, noticed that the
patient’s posture is slightly asymmetrical her right shoulder is slightly low compared to
her left shoulder. The student nurse asked her to lift both arms and was proven that
she cannot lift her arms evenly. Wrist and fingers were tested, the patient was asked
to spread her fingers and resist as the student nurse attempted to push the fingers
together to both hands. The patient was able to spread her fingers on her left arm but
had difficulty with her right arm. Lastly, Grip strength was also tested, the patient was
asked to grasp the student nurse’s index and middle fingers while she will try to pull
her fingers out. The patient was able to grip the fingers properly using her left hand
while the right hand was not able to grasp the fingers.
Norms:
The normal range is that the patient has a good posture, easy walks, transfers from
bed to chair, and walks fast not just slowly. In standing position, the torso and head
are upright. The head is midline and perpendicular to the horizontal line of the
shoulder and the pelvis. The shoulders and hips are levels, symmetry of the scapula
and iliac crests. The arms are free from the shoulders. The feet are aligned, and the
toes point forward. Walking initiated in one smooth rhythmic fashion (Jensen, 2019).
Analysis:
Upon the assessment, patient DML muscle strength on her right arm is weaker than
her left arm due to her condition, especially because of the numbness on her right
arm.
DOSAGE,
ROUTE and MECHANISM OF CONTRAINDICATIO NURSING
NAME OF DRUG INDICATION SIDE EFFECTS
FREQUENC ACTION N RESPONSIBILITIES
Y
Generic name: 50 mg/12.5 Losartan and its Losartan Hypersensitivity to CNS: dizziness, Before:
LOSARTAN WITH mg tab PO principal active Potassium/ thiazides, vertigo, Assess for BP
Inform patient
HYDROCHLOROTHIAZIDE OD in am metabolite block the Hydrochlorothiazide sulfonamides; fluid or paresthesia’s,
regarding drug
vasoconstrictor and is indicated for the electrolyte imbalance weakness, purpose and the
aldosterone- treatment of and to renal or liver headache, need to comply with
medications.
Brand name: secreting effects of essential disease. drowsiness,
During:
Hyzaar angiotensin II by hypertension in fatigue Check for rashes
selectively blocking patients whose CV: orthostatic and temperature
elevation daily
Classification: the binding of blood pressure is hypotension,
Monitor patient for
Combination of an ACE angiotensin II to the not adequately venous manifestation of
inhibitor and a diuretic. AT1 receptor found controlled on thrombosis, hypomagnesemia,
in many tissues, losartan or volume hyponatremia, and
hypokalemia
(e.g., vascular hydrochlorothiazide depletion, After:
smooth muscle, alone. cardiac Instruct patient to
adrenal gland). arrhythmias, report any adverse
reaction.
chest pain
Monitor BP closely to
Hydrochlorothiazide GI: nausea, evaluate
inhibits reabsorption vomiting, effectiveness of
of sodium and anorexia, dry therapy.
chloride in distal mouth, diarrhea,
renal tubule, constipation,
increasing excretion jaundice,
of sodium, chloride hepatitis,
and water by the pancreatitis
kidney. DERM:
photosensitivity,
rash, hives,
purpura
OTHERS:
muscle spasm,
cramps, fever,
gouty attacks,
hyperglycemia