13 AREAS OF ASSESSMENT
1. SOCIAL STATUS
Patient’s Data:
Patient FM is a 49 year old, born on February 14, 1972, is a married man. He is
living in Paniqui, Tarlac together with his wife and three children. He stated that he is the
bread winner of their family, he work as a carpenter for almost 20 years and his wage is
just enough to sustain their daily needs. Patient FM described his family as having strong
bonds and has good communication with each other and he believes that staying together
as a family is important in all circumstances. He enjoy simple activity as their bonding us a
family like cleaning their backyard, and spending the night before they go to sleeps.
Despite his medical condition, he manages to communicate and socialize with the medical
personnel during his assessment but he accompanies by his wife and translates what patient
does say when he experience difficulty in speaking or slurred speech.
Norms:
The ability to interact successfully with the people and within the environment
of which each person is a part, to develop and maintain intimacy with significant
others, and to develop respect and tolerance for those with different opinions and
beliefs.
This is a period of transformation, with a realization of mortality and a
concern for health. There is an increase in warmth and a decrease in negativism. The
spouse is seen as a valuable companion. (Fundamentals of Nursing: Concepts,
Process, and Practice, 10 Edition, 2018)
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Analysis:
Patient FM social status is described as normal. In times of coping crisis, he has a
solid support system through his family and he managed to interact despite his medical
condition.
2. MENTAL STATUS
General Appearance and Behavior:
During the assessment, Patient FM wears a t-shirt and jeans that are suitable for
his age. He appears to be well-groomed, neat, and clean. However, we observed he has
these grimace facial expressions, and he always held his neck due to the reasons of
experience stiff neck for about four days now and we observed his mouth is partially open.
Level of Consciousness:
On assessment, Patient FM seen to be awake, aware, coherent, cooperative, and
alert. He is sensitive to a variety of stimuli and is aware of time, date, and location.
Speech:
During the interview, Patient FM speaks Tagalog and utters a word in a slow tone
voice and slurred speech was observed.
Intellectual Function:
In the interview, Patient FM stated that he is a high school graduate, He tried to
get better-paying work, but he said he lacks sufficient education and training. However, he
was able to comprehend and respond adequately to the questions that were asked to him
Norms:
The patient should appear relaxed with the appropriate amount of concern for
the assessment. The patient should exhibit erect posture, smooth gait and
symmetrical body movement. The patient should be clean and well-groomed and
should wear appropriate clothing
for age, weather, and socioeconomic status. Facial expressions should be appropriate
to the content of the conversation and should be symmetrical. The patient should be
able to produce spontaneous, coherent speech. Content of the message should match
the patient educational level. The patient should be correctly responding to questions
and to identify all the objects as requested. Denial and poor eye contact is a normal
response on the first interaction that may be due to uneasiness in the presence of a
stranger or an attempt to screen or ignore unacceptable realities by refusing to
acknowledge them. The patient should demonstrate a realistic awareness and
understanding of self. The patient should be able to evaluate and act appropriately in
situations requiring judgment. Thought process should be logical, coherent and goal-
oriented. Thought content should be based on reality. (Health Assessment and
Physical Examination, 3rd Edition)
Analysis:
Patient FM has grimace facial expression it is due to sustained contraction of
facial muscle, he experience also stiff neck and mouth is partially open or lockjaw and
these are considered the most common early clinical features of generalized tetanus and it
appeared most common type of tetanus. He can speak but he utters words with low tone of
voice and slurred speech is noted due to pain he is experiencing. However, he was able to
respond to question appropriately and accordingly in situations requiring his judgment and
intellectual functioning matches his age.
3. EMOTIONAL STATUS
Patient’s Data:
Upon interview, Patient FM expressed that he was worried about his condition
especially he is the breadwinner in the family, he stated that if his condition worsens he
can’t provide for his family's needs and necessities. According to him, despite what had
occurred to him, his family, particularly his wife and three daughters, remained to support
and care for him.
Norms:
Normally, the patient should have the ability to manage stress and to express
emotion appropriately. It also involves the ability to recognize, accept and express
feelings and to accept one’s limitations. (Fundamentals of Nursing: Concepts,
Process, and Practice, 10 Edition, 2018)
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Analysis:
Patient FM can express that he is anxious about himself if his condition worsens.
He is worried for his family especially he is the breadwinner who sustains their needs and
necessity.
4. SENSORY PERCEPTION
Patient’s Data:
Sense of sight
As we assessed the patient eyes and use penlight, we observed the pupils are black
in color, equally round and reactive to light and accommodation, sclera was white. Eyes
were symmetrically moving upward, outward, inward, downward as we used the cardinal
fields of gaze test. As well as we test the visual acuity by using the Snellen eye chart
patient FM close his eyes and 20 feet meter away from the chart and we instructed the
patient to read the letters on the chart.
Norms:
The client who has acuity of 20/20 is considered to have normal visual acuity. The
eyes must be symmetrical during the six cardinal gazes test. The sclera should be white
with some small blood vessels. (Estes, 2014)
Analysis:
Patient FM has a 20/20 which is considered normal and good visual acuity.
Sense of smell
On assessment, Patient X was able to identify and classify the two cotton balls with
different smell which is alcohol and cologne. Nose is symmetrical and each of the nostrils
is patent.
Norms:
Nose must be symmetrical and along of the face. Each nostril must be patent and
recognize the smell of an object (Estes, 2014)
Analysis:
Patient FM sense of smell is normal
Sense of hearing
Upon assessment, we used whisper test and standing in the distance of 2 feet away
from the client, I whisper word in low pitch patient FM was able to determine the word
correctly in both ears.
Norms:
For the auditory acuity, the client should be able to repeat the whispered words
from a distance of two feet (Estes, 2014)
Analysis:
Patient FM has normal hearing acuity in her both ears. He can hear what words I
whisper to him
Sense of taste
In assessing the sense of taste, two different flavors were used particularly sugar
and coffee. Patient FM was able to determine the two flavors correctly, but he stated that
he had difficulty swallowing liquid and foods.
Norms:
A person usually identifies the taste of bitter, sweet, sour, and salty. By the use of
our sense of taste, we can fix or adjust the taste of our food based on our capacity.
Analysis:
Patient FM sense of taste is normal. He was able to determine the two flavors
correctly, however, he can’t swallow it immediately and he had difficulty because of
facial spasms as well as the lockjaw he was experiencing.
Sense of touch
We asked permission from the patient to touch him. He was also asked to close
his eyes and touched in right arm down to his fingers using the tip of the thermometer.
Patient FM was able to identify the site where he was touched.
Norms:
The skin contains receptors for pain, pressure, temperature. Sensory signals are
transmitted along rapid sensory pathways, and less distinct signals such as pressure of
localized touch are sent via slower sensory pathways. (Estes, 2014)
Analysis:
He has a normal tactile sensitivity and can easily identify the site where he was
touched.
5. MOTOR STABILITY
Patient’s Data:
During the assessment, we assessed the patient's range of motion. Patient FM stated
that he had limited movement in the upper portion of his body because he experienced
back pain and radiate to his neck, he can’t also easily move and rotate his head due to stiff
neck, facial spasm, and lockjaw cause difficulty in the mastication of food. However, he
can bend his elbows and farther apart or rotate, flexing and extending his knees and feet
but we observed his affected toes are inflamed and he stated that if they touched and move,
his big toes he would feel pain.
Norms:
Patient should have a smooth and well-coordinated movement. Her hands should
swing freely on the side. A patient should have a normal gait, able to walk in smooth and
steady manner. Abnormal findings might have hand tremors, uncoordinated movement,
stiffness, shuffling, shoulders should not be slumped (Hinkle & Cheever, 2018).
Analysis:
Patient FM has limited movement in his upper body due to back pain, stiff neck,
facial spasm, and lockjaw because the toxin tetanospasmin, which responsible for causing
tetanus binds to motor nerves that controls muscles, then enters to axons and travels in the
axon until it will reach the body of motor nerve in spinal cords or brainstem and this toxins
migrates into synapse where it binds to nerve terminals and inhibits or stops the release of
certain inhibitory neurotransmitter because of the motor nerve has no inhibitory signals
from other nerves, the chemical signal to the motor nerve of the muscle intensifies, causing
muscle to tighten up in huge continuous contraction or spasm causing patient experience
facial spasm that cause stiff neck and also lockjaw.
6. BODY TEMPERATURE
DATE AND TIME TEMPERATURE ANALYSIS
June 28
11:00 am
37.6 C Febrile
June 29
8:00 am
37.0 C Afebrile
June 30
8:00 am
36.7 C Afebrile
Norms:
Normal axillary temperature is within 36.4 to 37.4 centigrade. (Health
assessment and physical examination 3rd edition by Mary Ellen Zator Estes)
Analysis:
Patient FM has an increased body temperature on the day of admission, as a
result of the infection process, it will trigger the systemic inflammatory response towards
invading microbes which induce the hypothalamus to release prostaglandins which result in
increased body temperature which the patient experience. However, on the following days,
his temperature was 37.0 to 36.7 which is within normal limit.
7. RESPIRATORY STATUS
DATE AND TIME RESPIRATORY RATE ANALYSIS
June 28
11:00 am 23 cpm Above normal
June 29
8:00 am 20 cpm Normal
June 30
8:00 am 18 cpm Normal
OXYGEN SATURATION
June 28
11:00 am 95 % Normal
June 29
8:00 am 97% Normal
June 30
8:00 am 99% Normal
Norms:
A normal respiratory rate ranges from 12-20 cycles per minute. Average is
18 cycles per minute. Breathing patterns must be regular and even in rhythm. The
normal breath sound is bronchial which is high pitch, loud in intensity and blowing
or hollow in quantity. Bronchovesicular is moderate in pitch, intensity, and
combination of bronchial and vesicular. Vesticular is low in pitch, soft intensity,
and gentle rustling or breezy in quality. (Fundamentals of Nursing by Kozier, 7th
edition) A normal respiratory rate ranges from 12-20 cycle per minute. Average is
18 cycles per minute. Normal Oxygen saturation on the other hand ranges from
95%-100%. Breathing patterns must be regular and even in rhythm. The normal
breath sound is bronchial which is high pitch, loud in intensity and blowing or
hollow in quantity. (Hinkle & Cheever, 2018).
Analysis:
Patient FM respiratory rate on the day of hospitalization is slightly elevated which
cause by muscular spasm will affect the larynx, diaphragm, and intercostal muscle that will
affect normal breathing causing limited ventilator and cardiac reserve in addition to
decreased inspiratory and expiratory muscle strength. Upon auscultation, lung sounds are
clear with vesicular breath sounds and no wheezes, crackles, or rhonchi. On the following
assessment, respiratory rate was improved to 18-20 cpm. As well as his oxygen saturation
is normal within 95%-99%
8. CIRCULATORY STATUS
The circulatory status of the patient as well as blood pressure noted below:
DATE AND TIME PULSE RATE ANALYSIS
June 28
120 bpm Above normal
11:00 am
June 29
100 bpm Normal
8:00 am
June 30
95 bpm Normal
8:00 am
DATE AND TIME BLOOD ANALYSIS
PRESSURE
June 28
130/70 mmHg Above normal
11:00 am
June 29
120/80 mmHg Normal
8:00 am
June 30
110/80 mmHg Normal
8:00 am
Norms:
Normal cardiac rate for an adult is 60-100 beats per minute while the normal blood
pressure is 120/80 mmHg. Blanch Test was performed and the capillary refill is less than 2
seconds and is normal after it returned within normal state in 1-2 seconds. The pulse must
have a regular beat and not bounding nor weak. Blood pressure is not measured on the
client’s limb if it is injured or ill, has an intravenous infusion or blood transfusion. (Kozier
& Erbs, Fundamentals of Nursing, Tenth Edition)
Analysis:
Patient FM heart rate and blood pressure on the day of admission is above
normal due to toxins that cause spasms, it involves the autonomic nervous system
which results in tachycardia with but with regular rhythm and hypertension.
However, on the following days, the patient heart rate and blood pressure improved
and within normal range. A bounding pulse is felt radially and Blanch Test was also
performed revealed capillary refill is within 2 seconds.
9. NUTRITIONAL STATUS
Nutritional Parameters
Parameter Computation Norms Analysis
Height – Weight(kg)/ <16=Malnourished 16- Normal body
1.71 m [height( m)] ^2 19=Underweight 20- mass index
Weight – 59 (59 kg)/(1.71m)^2 = 25=Normal
kg 20.2 31-40=Moderate to severe
obesity
>40=Morbidly
obese
(Fundamentals of Nursing by
Kozeir, et al,.)
Norms:
Nutritional status represents the balance between nutritional and energy needs of
the body for carbohydrates, protein, fats, vitamins, and minerals, and the consumption of
these nutrients. Malnutrition or altered nutritional status, results from undernutrition and
over nutrition. Water consumption a day requires 8 to 10 glasses of water a day. Body
mass index (BMI) is a guide for maintaining ideal weight for height. BMI can be elevated
from larger muscles or edema rather than from excess fat. BMI of 18.5-24.9 is considered
healthy. (Hinkle & Cheever, 2018).
Analysis:
Patient FM has a difficulty in swallowing due to lockjaw and facial spasm they
ordered a specific type of diet which is liquid foods or food in liquid form since the
condition of the jaw does not allow or difficult to ingest whole foods. The patient
consumes 7-8 glasses of water each day and does not have any food allergy known. The
patient's height is 1.71 m and his weight is 59 kg with a body mass index result of normal
body mass index. He is a non-smoker aside from an occasional alcohol beverage drinker.
10. ELIMINATION STATUS
Patient’s Data:
Before admission, Patient FM urinates 2 to 3 times a day, a day in transparent
yellow color. He has no discomfort upon urination. He also defecates one time a day or
sometimes every two days.
Norms:
An individual normally defecates one to two times a day or every 2 days and
urinates 30 cc/hr and in voiding 3 to 4 times a day with an output of 1200 to 1500 ml
a day. A normal stool is brown in color and well formed, urine is clear to yellowish in
color. (Nutrition by Alex Abelos)
Analysis:
Patient FM urine is clear; light yellow with no presence of blood. No
presence of blood and difficulty in urination. Defecation as well as urination is
normal.
11. REPRODUCTIVE STATUS
Patient’s Data:
Upon admission, there were no abnormalities noted and there are no presence
of discharges, lesions, and tenderness upon palpation and other deviations from the
genitals and its surrounding area. The pubic hair is well distributed.
Norms:
Examination of the penis includes the skin, corporal erectile bodies, and
urethral meatus. It should be noted whether the patient is circumcised or
uncircumcised. The ease with which a redundant prepuce is retracted is assessed. The
entire penile skin, including that beneath the prepuce, should be examined for ulcers,
warts, rashes, or other lesions. The size and position of any skin lesion should be
described along with the degree of tenderness to palpation and fixation to
subcutaneous tissue. If penile skin lesions are found, correlation of palpable deep or
superficial inguinal adenopathy should be made at that time. Examination for urethral
discharge or urethral mucosal lesions near the meatus should also be carried out by
everting the lips of the meatus. (Maxwell White, Clinical Methods: The History,
Physical, and Laboratory Examinations. 3rd edition.)
Analysis:
Patient FM reproductive status is assessed and there is no significant deviation
from normal is seen.
12. SLEEP AND REST PATTERN
Patient’s Data:
Prior to admission, the patient’s sleeping pattern is normal with 7-8 hours of
sleep. He usually eats together with his family around 7 PM and sleeps around 9 o’clock
in the evening because he is tired from work and wakes up around 5:30 o’clock in the
morning so that he can prepare for his family breakfast and aside from that he will also
clean their backyard before he will go to work. However, two days prior to admission
patient experiencing a facial spasm and difficulty of open his mouth or lockjaw the
reason the patient having a hard time falling asleep. He frequently change his of position
in bed because of discomfort due to back pain.
Norms:
A typical sleeper will pass through 7 to 9 hours of sleep and take rest using
some relaxation such as reading, watching, telling stories and others. (Nursing
Fundamentals, Rick Daniels)
Analysis:
Patient FM sleeping pattern was altered due to pain and discomfort that bring by
symptoms of tetanus which causes the patients sleeping pattern interrupted.
13. SKIN AND APPENDAGES
Patient’s Data:
Patient FM hair is well-distributed and smooth to touch. The skin surface is not
tender to touch and palpation and returns to its original contour when pinched in 2-3
seconds. Moreover, we observed that there is the presence of inflammation and bruises
on his big toes, and the skin around it is warm to touch he remembered, he got this when
he accidentally punctured his big toes on the rusty nail in his workplace and he just
continues his work and washed it by running water after 30 mins.
Norms:
When the skin is pinched then released, it should return to its original contour
rapidly. Hair varies from dark to pale blonde based on the amount of melanin
present. Skin is dry with minimum perspiration. Skin surfaces should not be non-
tender. It should normally feel smooth, even and firm. There should be no presence
of edema. It must be warm enough to touch. (Health Assessment and Physical
Examination, Mary Ellen Zalor Estes)
Analysis:
Patient FM skin around the big toes puncture by a rusty nail, were observed to have redness,
edema, and bruises due to increased inflammation, circulation around the laceration, and
increased temperature was observed due to the inflammatory process.
