13 Areas of Physical Assessment

Social Status Mrs. E.M. 36 years old born on Jan 1, 1976 is a plain housewife. She resides at Quezon City together with her husband and with her 3 kids. Shes the one who takes care of her 2 daughters and her 1 son. She sometimes goes out of their house to talk with her neighbors. She does not stay too long along the streets because she tends to have an attack whenever she inhales street dust.

Mental Status Mrs. E.M. is oriented to time, place, events and person. She is able to recall recent and past events in her life. She is able to read and write and can speak in English and Tagalog. She is responsive and answers to the questions being asked.

Emotional State

Mrs. E.M. says that she feels a little stressed because of her confinement. Also, she is somewhat irritable because of her condition.

Sensory Perception Vision Hearing Smell Taste Touch Motor Ability Mrs. E.M. is lethargic and a bit weak. She can move freely in her bed but she needs help from her companion when sitting up and going to the bathroom. Mrs. E.M. only uses reading glasses. Mrs. E.M.s hearing ability is okay because she is able to answers our questions without us repeating it. N/A Mrs. E.M. claims that she can taste every food she is being offered. Mrs. E.M. responds to our touch.

Nutritional Status Before Mrs. E.M. was admitted she states that she eats at least three times a day. She is not picky with food. Her meal normally includes fish, pork, and vegetables. She is a normal beverage drinker. = lbs. / inch2 X 708 = =
.

BMI BMI

130 lbs. / 61.81 inches2 x 703 130 lbs. / 3820.5 inches x 703

23. 92 (NORMAL)
Below 18.5 18.5 24.9 25 29.9 Above 30

Underweight Normal Overweight Obese Body Temperature DATE Jan. 31, 2012 Feb. 1, 2012 TIME 8:00 AM 12: 00 PM 8:00 AM 12:00 PM

BODY TEMPERATURE (C) 37. 1 C 37.3 C 36. 2 C 36.6C

Respiratory Status DATE Jan. 31, 2012 Feb. 1, 2012 TIME 8:00 AM 12:00 PM 8:00 AM 12:00 PM RESPIRATORY RATE (cpm) 21 cpm 18 cpm 19 cpm 17 cpm

Circulatory Status DATE Jan. 31, 2012 Feb. 1, 2012 TIME 8:00 AM 12:00 PM 8:00 AM 12:00 PM BLOOD PRESSURE (mmHg) 120/80 mmHg 120/80 mmHg 120/80 mmHg 120/80 mmHg

Elimination Pattern DATE Jan. 31, 2012 Feb. 1, 2012 URINE 3 2 STOOL 1 0

Reproductive Status Mrs. E.Ms first menstrual period was when she was 10 years old. She got married at the age of 24 years old. She has 3 children (2 girls/1 boy) with 2 years gap each. She is sexually active.

Sleep Pattern Mrs. E.M. stated that she normally sleeps 4-6 hours/day, after she was admitted she has some difficulty in sleeping because of the nurses coming in and out of her room and sometimes she has difficulty of breathing. She usually watches television at home during rest hours and also during admission.

State of Skin and Appendages Mrs. E.M. has fair skin. Her wavy hair is up to her shoulders. Her lips are not dried and slightly brownish in color. Nails are trimmed.