XAVIER UNIVERSITY Diagnosis/Impression: Acute Myeolocytic Vital Signs: HR: 72bpm RR: 19cpm BP:

Leukemia (AML) 120/80mmHg

ATENEO DE CAGAYAN
Temp: 36.7⁰C O2 Sat: 98% Height: 5’2”
COLLEGE OF NURSING
Weight: 49kgs
NCM 101 RLE
History of present illness: II. CURRENT MEDICATIONS
PEDIATRIC ASSESMENT TOOL
Patient is diagnosed case of AML after bone Drug Dose/ Indication
I. GENERAL INFORMATION marrow done October 2008. Induction Frequency/
Name: XY Age: 13y/o phase chemotherapy done for only 15 days last Route
December 2008.
Birthday: 07/08/96 Birthplace: NaHCO3 650mg 1 tab To reduce the
incidence of
Cagayan de Oro City  *Note: Client was asked if he bid
chemical phlebitis
experiences pain and to rate pain in a and patient
Sex: Male Religion: Seventh pain scale of 10 being the highest and 1 discomfort.
Day Adventist being the lowest. Client answered, “
Address: B-10 L-10, Melecia Homes,
Sakit jud siya, mga 8 siguro.” “Nag Allopurinol 100mg 1 tab Management of
sige siya ug reklamo na sakit iyahang patients with
Macasandig Cagayan de Oro City, Misamis od
ulo”as verbalized by the mother. malignancies that
Oriental, Philippines result in elevation
of serum and
Current Educational Level: First Year urinary uric acid.
Highschool (St. Mary’s School Macasandig)
Tranexamic 500mg IVTT Treatment and
Informant: Mrs. XX, Client prophylaxis of
acid q8h
Relation: Mother hemorrhage
Past illness/ Medical/ Surgical History: associated with
Admission date: August 29, 2009 Time: excessive
9:13 am Illness Date fibrinolysis.
4 times admission Unidentified by
Chief complaint upon admission: Gum Significant Other Hydroxyurea 500 mg 1 tab Resist chronic
due to AML
Bleeding od myelocytic
leukemia
Attending physician: Dr. Fernando
Douglas Go, MD
*Note: “Sige siya kasukahon, tungod siguro ni OPV ___ ___ discoloration of the gingiva, and
sa iyang tambal”as verbalized by his mother. formation of masses.
Hepa B ___ ___

Drug Allergies: Measles ___ ___ Daily Food Intake (*Note: Client is supposed
to be in a soft diet but doesn’t want to eat the
“No allergies.” as verbalized by the mother. food served on the hospital.)
IV. ASSESSMENT OF SYSTEMS *Note: Mother verbalized complete but no
evidence shown. Breakfast: 1 cup rice and viand (specifically
Objective paksiw and sinigang which are his favorites).
V. NUTRITIONAL / METABOLIC PATTERN
General Appearance Lunch: 1cup rice and viand
Skin color: Fair complexion but pale in
Pale, weak, well-groomed; client manifest facial appearance. Dinner: 1 cup rice and viand
grimacing upon movement. Snacks: 1 pint ice cream and 2-3 pieces of
Lesions: Bruise noted on left wrist and right
Personal Hygiene/ Habits/ Grooming/ Hair knee. Red spots distributed all over the body. cookies

Hair is well-combed, neat, nails clean and well-
trimmed.
Clothing/ Manner of dress
Dresses neatly and appropriately.
Hair: Color: Black Texture: Smooth
Lesions: None
Nail Color: Pink nail beds
Condition: Nails are round, intact, firm,
smooth and with good capillary refill.
Food Supplements / Vitamins Taken:
Fern-C, Cherifer PGM, Herb supplement
Food Allergies: “No food allergies” as
verbalized by the mother.
VI: ELIMINATION

Immunizations received: Oral mucosa: Teeth: Impaired, especially the Bowel Habits:
central incisor and the lower molars.
Frequency: Once a day
Immunizatio Date Place
ns Received Received  Condition: Oral mucosa is moist. Dental
Consistency: Soft
carries are present. With regards to gum
BCG ___ ___ condition, mother states, “Ga-dugo
Color: Brown
iyang gums”. Mother added, “Naa ko
DPT ___ ___ mga nakit-an na burot sa sulod sa iyang Amount: Depending on food intake
baba.” Presence of halitosis,
Bladder Habits: Hearing: Client states, “medyo gakabungol- DEVELOPMENTAL MILESTONES (Infant to
bungol ko these past few days”. Adolescent)
Frequency: 4 times a day
Smell: Good sense of smell; can identify odors. Psychosex Psychoso Cogniti
Amount: Depending on fluid intake ual cial ve
Aids for vision: None
Color: Amber straw Infancy Able to suck. Needs were Manifeste
Aids for hearing: None Thumb met and d hand-
*Note: Mother answered, “Dili kaayo siya sucking. Puts developed a mouth and
gainom og tubig.”, when asked about his fluid X. COGNITIVE any objects sense of eye-ear
intake. into mouth. trust. Child coordinati
Ability to express: Speech is clear with Needs are learned to on.
satisfied love and be Experienc
moderate pace. Responds appropriately to
VII: ACTIVITY-EXERCISE through loved. ed
topic discussed; expresses feelings appropriate sucking. separation
Daily Activities: Kasagara nako buhaton kay to situation. Expresses good feelings about anxiety
mag-play games sa PSP and computer, watch self; verbalizes positive coping mechanisms. when
Expresses full and free-flowing thoughts during mother
TV dayon. leaves.
interview.
Leisure Activities: “The same lang.” as Toddler Toilet trained. Learned to Egocentric
verbalized by the client. XI. ROLE-RELATIONSHIP PATTERN Able to be .
control independent Displayed
Exercise Routine: Walking Ordinal position of client in family: Eldest micturition in decision- static
and making. thinking.
VII. SLEEP-REST Primary caregiver of client: Mother, cousin defecation.

Other support system: Relatives Prescho Identifies Learned how Lack of

Time of Sleep: 8:00 pm-6:00 am parent of the to do things reversibilit
ol
opposite sex. and solve y.
Sleep Aids: Cuddled pillow Child learned basic
sexual problems.
Quality: Continuous identity Has the
through initiative in
IX. SENSORY-PERCEPTUAL awareness of doing things.
genital area.
Vision: Clear with pupils reactive to light; no
reported vision problems. School- Actively Learned how Able to
participated to do things use
age in school well. memory to
activities. Industrious. learn new
concepts.
Able to
classify
objects.
Awareness
of
reversibilit Body Map: (Illustrate in the body map how Laboratory/ Diagnostic Results (include
y.
your patient looks like e.g. tubes inserted, and interpret results)
Adolesc Developed Learned what Solves bruises, surgical incisions, physical
sexual kind of hypothetic abnormalities, affected areas. Mark with a a.) CBC
ent
maturity. person he is. al
small “x” where it is located or draw it on the Total WBC 78.9
Likes to hang- Able to problems
out with express using body map and then label.) 5.0-10.0
friends of feelings well. scientific
opposite sex. reasoning. _____________________________________ Total RBC 3.01 3.69-
Likes to 5.90
talk. Describe affected areas Red spots distributed
all over the body. Bruise noted on the right Hemoglobin 8.4
knee due to bump and at the left wrist due to 13.70-16.70
IV insertion.
Hematocrit 27.2 40.0-
49.70

MCV 90.4 70.0-

97.0

MCH 27.9 26.10-

33.0

MCHC 30.9
32.0-35.0
Platelet Count 7
150.0-390.0
b.)Differential Count

Neutrophils 4.0
37.0-72.0

Lymphocytes 92.0
20.0-50.00

Monocytes 1.0 8.00-

14.00

Eosinophils 3.0 0.00-

6.00

Basophils 0.0 0.00-

1.00

RDW-CV 17.1 11.50-

14.50

c.)

 Atypical cells seen

 Immature cells seen