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The premier University in historic Cavite recognized for excellence in the development of globally competitive and morally upright individuals.

University Mission
Cavite State University shall provide equitable and relevant educational opportunities in the art, sciences and technology through quality instruction and responsive research and development endeavors. It shall produce professional, skilled and morally upright individuals for global competitiveness.

Republic of the Philippines CAVITE STATE UNIVERSITY DON SEVERINO DE LAS ALAS CAMPUS Indang, Cavite College of Nursing

SCHOOL AGE

Submitted by: Jenivic Puedan

Submitted to: Ms. Karen Louella Rint, RN

Demographic Data A. Initials of Clients Name: C.M B. Address: Asis, Mendez Cavite C. Age: 7 years old D. Birth Date: December 10, 2005 E. Birth Place: Bohol, Negros Occidental F. Gender: Female G. Civil Status: Single H. Religion: Catholic Date of Admission: December 04, 2012

II. Reason for seeking health care

The client has no reasons for seeking health care.

III. History f Present Illness

The client has no history of present illness.

IV. Past Medical History The client C.M has no problems at birth. According to the client she has fever last November 28, 2012 in 1 day. . The client took paracetamol for her medication.

The client stated that Hindi ko po alam kung lahat ng bakuna ay natanggap ko, pero binakunahan nap o ako sa center nung maliit pa po ako. According to her, she hasnt had any kind f accident or injuries yet.

V. Heredo Familial History Genogram

PATERNAL SIDE
P.M 34 Y/O A& W

MATERNAL SIDE
D.M 33 Y/O A&W

T.M 9 y/o

C.M 7 y/o

J.M 5 Y/O

P.M 3 Y/O

R.J 2 Y/O

I.M 1 Y/O

LEGEND: MALE CLIENT

FEMALE A&W- Alive and Well

INTERPRETATION: The diagram above shows the family structure of client C.M that they are 6 children of P.M and D.M. As shows at the diagram she has 5 siblings in a short period of age gap to each other. The diagram shows that the their family has no disease that an occurs inside their family.

VI. Gordons Functional Health Pattern

Health Perception- Health Management The client stated that Malusog naman po ako . According to the client if she is experiencing fever or any kind of illness she tell her mother first and take medication. If her illness hasnt cure in a first 3 days, thats the time they go for check up. Pag may sakit po ako ay nainom lang po ako ng maraming tubig at nagpapahinga, as verbalized by the client.

Nutritional Metabolic Pattern

According to client C.M she east tries a day, it consist of more meat and less vegetables. Client C.M has no vitamins or any medication taken to build her immune system. Her weight is 17 kg and a height f 118 cm. According to the growth chart of World Health Organization (WHO ) the normal weight of a child under age is 17 35 kg and the height is 108-135 cm. Client C.M has a normal body weight and height according to WHO. The child stated that Minsan lang po ako nakain ng gulay at ayoko po talaga ng gulay.

3 Day Diet Recall

Meals Breakfast

December 01,2012 Rice+ egg + 180 ml of water Biscuits Rice+ pancit + 120 ml of water

December 02,2012 Rice+ hotdog + 180 ml of water Biscuits Rice+ pancit + 120 ml of water ---------------------------Rice+ noodles + 120 ml of water 420 ml

December 03,2012 Rice+ can goods+ 180 ml of water Biscuits Rice+ pancit + 120 ml of water ---------------------------Rice+ vegetables + 120 ml of water 420 ml

Snacks Lunch

Snacks Dinner

----------------------Rice+ vegetables + 120 ml of water

Total fluid intake:

420 ml

Interpretation: The table above shows that client C.M has a lack of fluid intake; she consumes 420 ml per day. According to World Health Organization at her age the child must consumes 8 t 10 glasses a day or 1980 ml 2400 ml every day. It shows also that the child eats more meat and can goods than vegetables. Client C.M admitted that she dont like to eat vegetables every day.

Elimination Pattern According to the client, she urinates three times a day with yellowish in color. She defecates once a day with brown colored stools. She has flat abdomen and has bowel sounds.

 Activity Exercise Pattern

The client is a quite and shy type of child. Mahiyain po talaga ako, minsan hnidi po amk sumasali sa mga kalaro ko, lalo na pag mga lalaki. Gusto ko mga babae lang ang mga kaibigan ko verbalized by the client. According to Pillitteris Dvelopmental Milestone a 7 year old child appears quiet compared with a rough and tumble 6 year old. Gender differences usually begin t manifest in plays, these are girl game such as dressing dolls. The client stated that she do household chores like cleaning the house and wash the dishes. Also client C.M takes good care of his youngest brother every weekend because her parents go to work for living. Katz Index Activities Bathing Dressing Toileting Transferring Continence Feeding Total points: 6 . Independence = 1 pt. Dependence= 0 pt

Interpretation: The table above shows that client C.M can do all the activities in KATZ INDEX. Client C.M is 7 years old; according to Pillitteri at her age the client can do all these activities.

 Sleep Rest Pattern.

Client C.M usually sleeps 8-9 hours a day. According to the client she watches television before going to bed. She dont use any aids for sleeping but she has routines like taking half bath and changing clothes before sleep.

Cognitive Perceptual Pattern Client C.M is a 7 year old, according to Pillitteri at this age, schoolers are in quiet year and conservation is learned. At C.Ms case she wants to be alone sometimes. Mahiyain po talaga ako. According to the client there is nothing wrong with her eyes. Okay naman ang mata ko,nakakakita naman ako ng maayos as the client stated. Client C.M can also hear normally. During my assessment to the client she ask me if I know how to read watches . According t the client she doesnt know how to read it. Hindi po ako marunong tumingin ng oras as the client stated. According to Pillitteri at the age of 7 years old schoolers can tell time in hours. At client C.M case she cant tell me the time exactly. Client C.M was able to follow and answer questions directly. The client told me that she cant make decisions by herself,according to her she wasn;t able to do that because f her age, she needs guardian to decide.

 Self Perception Self Concept. Client C.M admitted that she has an anxiety to others in the scae of 4. Shes a quit kind of person. Mahiyain po talaga ako as the client stated. According to her she is a good daughter to her parents and to her siblings as well.

Role Relationship Pattern Client C.M has 5 siblings; her parents go to work fr their living. According to the client shes the one who takes good care of her younger siblings. She do also household chores together with her oldest sister.

Coping Stress According to the client she usually deals with her problems by playing dolls. Naglalaro na lang po ako ng dolls pag my problema as the client stated. The client said that she tells her mother about the problems that she encountered.

Value Belief

The family that C.M belongs is Roman Catholic; they usually went to church every Sunday together with her older sister. According to the client she performs her religious practices by praying before sleeping.

VII. Developmental History A. Freuds Psychosexual Developmental Theory

According to Sigmund Freuds psychosexual developmental theory, asserted that human behavior is motivated by psychodynamic forces within an individual unconscious mind. He describes adult behavior as being the result of instinctual drives that have a primarily sexual nature (libido) that arise from within the person.

Stage 4

Specific Taks (s) Latent Stage

Evidences of Milestone Achievement In Freuds 5 stages namely: oral, anal, phallic, latent and genital. Client C.M belong in the latent stage which children libido appears to the diverted into concrete thinking, the client childs personality developed appears to be non active or dormant. The client cant deal with her classmates or friends because of anxiety and a quiet stage. According t Pillitteri a 7 year old appears quiet and begin to manifest in play.

B. Erik Eriksons Theory of Psychosocial Development

In the theory of Eriksons it discuss about the stresses that importance of culture and society in development of the personality. The main tenets of his theory are a persons social view of the possibilities for human growth.

Stage 4

Specific Taks (s) Industry vs. Inferiority

Evidences of Milestone Achievement Client C.M is in the stage of industry vs. inferiority because at her age, she takes good acre of her youngest brother and according to C.M ,her mother praised her and says god things about what she have done. And also her mother gave her a reward by buying her needs at school.

C. Piagets Theory of Cognitive Development

According to Piagets theory of cognitive development, a person must progress to learn , to think, reason out and exercise judgment and to learn the cognitive skills needed t adapt his/her environment. In child case shes belong in the stage 3 of Piagets theory the concrete operational thought.

Stage 3

Specific tasks Concrete operational thought

Evidences of Milestone Achievement At her age of 7 years old conservation of number is learned. During assessing client C.M, the client shows me money at her packet and shes counting it. According to the client, her mother gave her 15php per day but client C.M can mange her money into two days. The client stated Tinitipid kop o an gang baon ko para my baon pa ako bukas.

D. Khlbergs theory of Moral Development In the theory of Lawrence kohlbergs moral development theory, it tackles how to recognizingor identify how children may feel about an illness such as whether children think is fair that they are ill and also recognizing moral reasoning to help to determine children can be dependent on to carry out self care activities. At client C.M, shes included in stage 3 conventional development a level at which many adults continue to function, and young school age children adhere to a phase of development the nice girl, children engage in actions that are nice or fair.

Stage 3

Specific tasks Conventional development

Evidences of Milestone Achievement After my assessment to client C.M. I gave her a food, then she called her classmates then she says Binigyan ako ni ate ng pagkain,tara kainin natin. Client C.M shows kindness to her friends which is showing a good attitude.

Comprehensive Physical Examination A. Vital Signs T = 36.7 C PR = 77 RR= 33 B. Anthropometric Data Height = 118 cm Weight= 17 k Date/Time of Examination: December 04,2012

Physical Examination
Parts Skin and Extremities Technique Inspection Objective Dry skin No lesion Findings Abnormal Normal

Palpation Hair Inspection Rough to touch (+) lice (+) dandruff (+) rough

Abnormal

Abnormal

Palpation Nails Inspection Dirty finger nails Oily No masses Normal Abnormal

Palpation Skull and Face Inspection

Smooth Normocephalic Aligned facial features Normal

Palpation Eyes Inspection

No modules No masses Aligned No edema No tearing Normal

Ears and Hearing

Inspection

Same color as facial skin Symmetric

Normal

Palpation Nose and Sinuses

Smooth No tenderness Symmetric Straight No discharge or flaring Normal

Inspection

Palpation Mouth and Pharynx Inspection No tender No lesions Uniform in pink Normal

Palpation

Soft Moist smooth Complete teeth Normal

Teeth and Gums Inspection

Neck

Inspection Palpation

Symmetric No lesion No masses No palpable Lymph Nodes Middle Position Symmetric No tenderness

Normal

Lymph Nodes Trachea Thorax and Lungs

Palpation Palpation Inspection Palpation

Normal Normal

Auscultation

No adventitious sounds

Breast and Axillae

Inspection

Areola darker in color

Normal