I.

PATIENTS PROFILE

A. Biographical Data Name: Age: Sex: Status: Religion: Place of Birth: Birthdate: Address: Date interviewed: Informant: Date admitted:

Patient X 1 year old female child

Chief Complaints: Prior to admission, patient has temperature ranging from 36.3 39.5C, with non-productive cough and vomits in small amount every after breastfeeding, characterized as whitish in color that started 3 days PTA. Admitting Diagnosis: Final Diagnosis: B. History of the Patient 1. Present History It started when she vomits in small amount (approximately 5 ml) of vomitus after every breastfeeding, characterized as whitish in color. The next morning, she had a fever of 38.9C with nonproductive cough. With these conditions, her parents decided to sought a doctor, hence, the doctor prescribed Paracetamol Syrup 5 ml every 4 hours for fever. After the consultation was done, and the prescribed medication was taken, the fever went on and off (temperature ranging from 36.3 39.5C. still the child vomits in a small amount after every breastfeeding. Since the child hasnt shown any progress in her condition, the

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family rushed her to atok district hospital and was diagnosed to have bronchopneumonia and was admitted. 2. Past Medical History When she was still 2 months old, the child was admitted in a health clinic in senepsep, Benguet for 3 days due to her primary complaints of cough and fever. However, the mother claimed that they were not informed about the diagnosis of her childs illness at that time. No previous accident and surgery had occurred. The patient has no known allergies to food and drugs. 3. Family History History of hypertension on both sides of her parents was present. However, on her father side, they have a family history of anemia. 4. Social and Environmental History The patient belongs to the Kankanaey group. The patient is the 3rd child of her parents. They live in a small house ith two bedrooms. Their place has a cold climate, thus cough and colds are common. Both parents are farmers in their town. The patient is always with her parents wherever they go. Trees and plants surround the house, and the spaces between houses are at least 100-300 meters away, as approximated by the parents. 5. Immunization History Immunizations were completed before she reached the age of 1 year old.

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II. 13 AREAS OF ASSESSMENT

I. II. III. IV. V. VI. VII.

Elimination Status The patient uses diaper. She consumes 4-5 diapers (weigh ranging from 0.5 2 kgs) a day totally soaked with urine. She defecates 1-2 times a day with a soft, orangeyellow stool. She did not yet achieved daytime and nighttime bladder and bowel control. No perspiration noted during febrile episodes. Fluid and Electrolyte Status Patient has an IVF of D5 0.3 NaCl 500 ml x 8 hours for the first two bottles followed by the infusion of the same IVF to run for 12 hours. It is infusing well at her left arm. She breastfeeds most often and it is her only source of nutrients at this time. No edema noted, with good skin turgor. Circulatory Status Patient has a heart rate of 124-156 bpm on the apical area. The quality of heartbeat is in regular rhythm. Paleness on the nail beds is present. No clubbing of fingers is noted. Respiratory Status Patients respiratory rate is 36-52 breaths per minute, pattern is regular but the rhythm is fast. Crackles are heard on both lung fields upon auscultation. Nonproductive cough is noted with nasal flaring, pale nail beds. Stridor on inspiration was noted upon admission, and was ordered with 1 L/min oxygen via mask inhalation. Wheezes were heard on the left upper quadrant of the lung 2 days after admission.

VIII.

IX.

X.

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XI.

Temperature Status Patient has intermittent fever with temperature ranging from 36.3 39.3C by axilla, thus, she manifests flushed skin and she is warm to touch. Integumentary Status Patient is warm to touch with flushed skin; with capillary refill of 1-2 seconds, and with good skin turgor. There were no lesions, wounds or incisions and diaper rash noted. Comfort and Rest Status Patient sleeps most often and only wakes up when discomfort is felt during drug administrations. Her mother claimed that theres no change in sleeping pattern before and during hospitalization. She mostly sleeps for 12-14 hours a day including the naps. The child sleeps with her parents at home.

XII.

XIII.

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