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13 AREAS OF ASSESSMENT I. Social Status Demographic Data Mr.

Y is a 61 year old male, Born on December 2, 1951 via NSD by a midwife. he is the eldest of the 4 siblings. The Family resides in kayapa, nueva viscaya he has 3 offspring, all children are currently working and has their own family. Socio-Economic Factor Mr. Y belongs in an extended family, Roman Catholic and a farmer, while his wife works as a vendor in the market both are high school undergraduate with a family income of 5,000.00 pesos per month which according to Mr. Y are sometimes insufficient to meet their basic needs. Environmental Factor Mr. Y resides in a medium size house made up of concrete with 3 rooms and 2 large windows which resulted to good ventilation. The house is located in a congested area. Artesian well is their source of water. Their excreta disposal is with water carriage. II. Mental Status Mr. Y is conscious and cohisent, oriented to time and date, he is a high school undergraduate and is able to read and write and follow instructions, able to maintain eye to eye contact. His chronological age is directly proportional to his developmental age whise his focus includes financial security, career and family according to Sullivans stages of development. He is open and approachable and is able to converse with the student nurses. During Assessment, Mr. Y talks about his childhood memories, showing that his long term memories are still intact. III. Emotional Status Prior to hospitalization, according to Mr. Y, heis very cheerful, heloves to make conversations with their neighbors, sisters and his wife. During hospitalization before the operation, Mr. Y is still very cheerful and makes some jokes during assessment. During admission, Mr. Y became very irritable due to pain, but still hestated that they have financial problem since his work is contractual and sometimes he dont go to work due to the pain he feels when his rheumatoid arthritis occurs although their children helps in supporting them financially and emotionally. This shows that they have a good relationship status with his family. IV. Sensory Perception Vision In assessing the vision, patient is instructed to look straight to observe the general appearance of his eyes. Eyes are almond in shape, irises are black in color, and sclera is whitish in color, eyebrows and eyelashes are equally distributed. His conjunctiva is pale and moist, Patient is

also instructed to follow the direction of a finger with his eyes following six cardinal positions, and his eyes were able to move in full range of motion and in all directions. With the use of a penlight Pupils are assessed, Pupils are equally round and reactive to light accommodation. The patient does not use eyeglasses or contact lenses. visual acuity is assessed by asking the patient to read the word written in apiece of paper with a font size of 12 about 3 feet away from his using the right eye first then left eye and then both eyes. Then test was repeated but this time it will be only 1 foot away from his using the same procedure. Different words were use written in different paper in every test. Mr. Y read all the samples during the test. Smell Clients nose has no deviation in terms of shape and size, nose is pointed and no discharges were seen during assessment, according to the patient, he doesnt have any history of sinus infection or epitaxis. Before the next procedure, permission was asked to the patient to do another test, using a peeled apple and the skin of an orange, without the patients knowledge, we ask him to identify the two samples by smelling. After smelling hecorrectly identified the two fruits. Test shows that these are no abnormalities or obstructions were identified in the sense of smell. Hearing General appearance of Mr. Ys ears were parallel, symmetrically proportional to the size of the head, bean shaped, firm cartilage and with a presence of cerumen. In assessing the hearing acuity of the patient, Mr. Y is instructed to repeat the words that will be whisper at a distance of two feet away on the left ear first, then right ear after the test, hewas able to repeat the whispered words. Taste Mr. Ys lips were moist and symmetrical in shape; tongue is pinkish in color, with presence of tooth Decay, with partial dentures, no signs of gingivitis, buccal area are moist. We assess using a tongue depressor. To assess his sense of taste, Patient is asked to do some test. Hewas asked to taste a pinch of sugar and a pinch of iodized salt without knowing the two samples are. After the test Mr. Y identified the two samples correctly. Touch In assessing Mr. Ys sense of touch, hewas asked to close his eyes, a cotton ball was stroke to the back of his neck, then using anothis cotton ball, we poured an alcohol on it and rubbed it on the same area, and hestated that hefelt a sensation of wet and cold on his skin. Using the case of BP apparatus which is rough in texture and the medical kit which is smooth in texture, the patient is asked to touch the two materials and ask the texture while blindfolded. After the test, hecorrectly identified the difference of two materials.

V. Motor Ability Upon confinement, patient is asked to perform R.O.M exercises on the upper and lower extremities. He was asked to raise both his arms. He performed it with ease and freely moves without any difficulty. He can bend and straightened his elbows and extend and spread his finger she was able to move it slowly. According to the patient, he usually has leg cramps that occur anytime of the day especially when lying in high-fowlers position. These are no presences of deformity; these are also proper symmetry between left and right side of each extremity. Upon confinement, the patient was instructed to remain flat on bed for a few hours after surgery, and then early ambulation was encouraged. Patient can bend his legs and arms with limited range of motion and needs assistance when standing and going to the comfort room. VI. Temperature Mr. Ys is febrile In august 4, 2012; temperature is at 38.0 C taken at Right xilla that deferred him from being discharged from the hospital. VII. Respiratory Status His chest expansion was symmetrical with ease during respiration. Rhythmand respiration pattern are regular. He has an ineffective airway clearance and ineffective breathing pattern which provide inadequate gas exchange and resulted from the occurrence of Hospital acquired pneumonia. Lungs were auscultated for adventitious sounds, after auscultation, crackles were heard over the both lung fields. . No supraclavicular or suprasternal retraction was seen during inspiration. VIII. Circulatory Status Taken at radial pulse, his capillary refill is within 1 to 2 seconds taken at right Forefinger, pulse scale is 2 + which is easily palpable. Blood Pressure His blood pressure ranges from 140-150 systolic and 90-110 diastolic Taken at his left brachial artery, negative for peripheral edema. IX. Nutritional Status Prior to hospitalization, Mr. Y stated Madalas isda ulam naming tapos konting gulay . He drinks about 7 to 9 glasses of water a. He has a good appetite prior to operation. During hospitalization, the clients appetite decreased due to loss of appetite. X. Elimination Status

Mr. Y stated that prior to admission ; he defecates once a day every morning with a semi-solid consistency without difficulty. He urinates 4 to 5 times a day approximately 50 to 70cc per urination according to Mr. Ys statement. Urine is amber in color. During hospitalization , the patient has a diaper and IFC connected to urine bag with amber color urine with a recorded urine output of 400cc with an IVF input of 700cc. He has episodes of constipation during confinement and was given lactulose to promote bowel elimination. XI. Physical Rest and Comfort Prior to hospitalization, Mr. Y sleeps 4 hours a day without any routine going to sleep. He stated Lagi akong puyat, apat na oras lang madalas ang tulog ko basta may chance matulog aymatutulog talaga ako kaso sandali lang talaga. During confinement, the patient usually sleeps within 6 to 8 hours at night and wakes up during medication then he usually takes a nap at day time. Patient is uncomfortable due to pain He stated during our post-op assessment to his pwedeng mamaya na lang, masakit talaga yung opera sa akin. Heusually lies on bed. XII. State of skin and appendages Skin Prior confinement, Mr. Y has good skin turgor with no history of skin allergy, no presence of tattoo, no bed sore, and no skin lesions. Patient has a fair complexion. During confinment , the clients skin turned into a slight pale in color in the second day, temperature is warm to touch but with good skin turgor, and no presence of bedsore were seen. Hair Presences of dandruff were seen during assessment, no lice were seen, and patient has thick curly hair. Hindi na ako nakakapaglinis ng katawan ko, ni hindi ko magawa ang makapagayos o makapagsuklay man lang, as verbalized by the patient Nails During confinement, Nails are pinkish in color, no signs of clubbing.