I.

Assessment
Sex: Male Age: 1 year old Religion: Islam

Data Base and History

Name of Patient: Baby Boy Civil Status: Single (Child) Nationality: Filipino

Address: San Roque Mambaling Cebu City Occupation: Not Applicable Date Admitted: January 26, 2013 Age: 28years old Temperature: 36.6 C Time: 6:00 AM

Informant: Cheryll Garcia Jamis (Mother) Respiratory Rate: 52cpm Weight: 8.2kg

Pulse Rate: 140 bpm

Height: 67cm

Nursing History
A case of 1year old baby boy with chief complaints of persistent cough with difficulty breathing (labored breathing) noted 1day prior to admission. Cough started 2days before admission with no fever.

Nursing History
I. INFORMATION DATA
Age: 1 year old Sex: M Religion: Islam Name of Patient: Baby Boy

Address: San Roque Mambaling St. Cebu City Husband/Wife/Parent`s Name: Cheryll Garcia Jamis Accompanied by: Cheryll Garcia Jamis Relationship: Mother

Mode of Admission: came in to the hospital with baby carried by mothers arms Complaints upon admission: Persistent non-productive cough with labored breathing

II.

PERSONAL AND SOCIAL HISTORY

A. FAMILY HISTORY Father Alive Deceased Mother Alive Deceased Cause of Death: Cause of Death:

Rank in family: 4th No. of children (if married): NONE Educational Attainment: NONE Occupation of Wife/Husband/Parents: Kitchen Steward at Water Front Hotel Other Source of income: None B. LIVING CONDITIONS House Owned

Rented

Shared If shared, with whom: Husbands Parents

Concrete

Semi-concrete

Nipa and bamboo Mixed No. of rooms in the house: 3 No. of persons staying in the house: 10 C. NUTRITION Usual Time to take breakfast: 6am Lunch: 12pm Usual snacks in between Meals Yes Note: Sometimes bread as stated by Mother

Supper: 7pm No

Food Likes: Fruits, Lugaw with chicken shreds, Rice with mashed squash Dislikes: N/A Usual amount of water intake per day: (Specify the number of glasses): 2ounces after feeding and when needed (approximately 6ounces a day) D. SLEEPING PATTERNS Usual sleeping time Takes a nap: Yes Time: 9 Am, 2:30 Pm No Note (2times a day) Awakens at night: Yes Time: No Snores Teeth Grinding Talks Others (please specify): Comfortable sleeping position Supine Prone Side-lying Others (please specify): E. ELIMINATION PATTERNS Frequency of bowel movement: Daily Weekly

Others: __________________________

Usual Time of defecation: Once 6 Am Consistency: Hard formed stools Color: Yellowish Frequency of urination / day: Changes diapers 2-3X per day Color: Clear F. PHYSICAL HYGIENE Frequency of bathing Once a day Twice a day Thrice a day Other (please specify): morning 8am and night 6pm Shampooing of hair Daily Once a week twice a week Others (please specify): with baby bath Frequency of hand washing Before and after meals As Necessary Others (please specify): Frequent Frequency of tooth brushing Every after meal twice a day once a day Others (please specify): G. ENVIRONMENTAL SANITATION Water Source MCWD Artesian Well Others (please specify):

Deep well

River

Water Storage By jar By pail By pitcher Other (please specify): Mineral water with dispenser Mode of Human waste disposal: Flush Water sealed Pit Others (please specify): patient stated they have their own bath room Garbage disposal Burning Compost pit Trash can Note: as stated by the Mother Adunay Garbage truck nga mo kuha sa among BASURA H. SOCIAL ACTIVITY Sports: N/A I. Habits: N/A Vices: N/A Drinking (alcoholic beverages) Frequency: N/A Gambling Frequency: N/A Smoking Cigarette No. of sticks/ day: N/A Tobacco No. of sticks/ day: N/A

III. MEDICAL HISTORY

A. HEREDOFAMILIAL DISEASES Diabetes mellitus Cancer Mental Illness Asthma Hypertension Others: B. COMMUNICABLE DISEASES OCCURING IN THE FAMILY Tuberculosis Hepatitis Hansens disease Others (please specify):

OBSTETRICAL AND GYNECOLOGY Menstruation Onset: N/A Duration: N/A Cycle: N/A Character: N/A Discomforts: N/A Gravida: N/A Para: N/A Abortion: N/A No. of Siblings: None Difficulty encountered during pregnancy Age of menopause

C. PREVIOUS ILLNESS/SURGERY Note: A case of 1year old baby boy, been hospitalized for 2x on October 2012 and December 2012 with same case of Pneumonia PRESENT ILLNESS Note: Pediatric Community Acquired Pneumonia (PCAP) Pneumonia is a lower respiratory condition characterized by the inflammation or infection of the pulmonary parenchyma. It is caused by bacteria, virus, fungi or by the aspiration of a foreign substance.

Nursing Assessment
General Appearance:
The patient was awake, conscious and afebrile when assessed and interacts with the student nurses.

The vital signs upon assessment are as follows

Temperature: 36.6 C Pulse: 140bpm Respiratory: 52cpm Weight: 8.2 kg. (18 Pounds) Height: 67cm (2.2 feet)