I.

ADMISSION/ FINAL DIAGNOSIS

AGE w/ some DHN

II. HEALTH HISTORY AND PHYSICAL EXAMNINATION

A. Demographic (Biographical Data)

1. Client’s Initial: G.J. Francisco
2. Gender: Male
3. Age, Birthdate and Birthplace: and 8yrs old, October 31, 2000,
Tramo, Rosario Cavite
4. Marital (Civil) Status: Single
5. Nationality: Filipino
6. Religion: Catholic
7. Address and Telephone Number: Tramo, Rosatio Cavite,
091053349233
8. Educational Background: Grade 3, Bagbag II Elementary School
9. Occupation: Student
10. Usual Source of Medical Care: Clinical Hospital
11. Date of Admission: November 30, 2009

B. Source and Reliability of Information

Client’s mother, R. Palma who seems reliable

C. Reasons for Seeking Care or Chief Complaints

“Nagtatae siya at nagsusuka” mother verbalized.
“Wala din siyang gana kumain” mother verbalized.

D. History of Present Illness or Present Health

Onset of symptom began the day the client was admitted.
When the mother’s patient was asked when was her daughter
loose bowel movement started she answered with this statement,
“kahapon nagsimula ang pagtatae niya, nagsuka din siya pero
isang beses lng. “ The mother also verbalized, “mula umaga
hanggang ngaung hapon, apat na beses na siyang dumudumi.” As

Location – “sumakit po yung tiyan at lalamunan ko pero nung

naconfine na po ako dito, umayos na pakiramdam ko.”

Quality (Character) – “para pong nagasgas ung lalamunan ko at

para pong lagging nadudumi yung pakiramdam ng tiyan ko.”
 Quantity/ Severity – “madami dami yung mga nasusuka nia kapag
sumsuka siya, para bang kalahati ng maliit ng baso ung dami.” As
verbalized by the client’s father.
Setting – “nagsimula po akong magsuka sa bahay, hindi naman po
ako nagsuka noong nasa iskul.”

Associated Phenomena/Factors – “noong nagsusuka po ako,

pakiramdam kop o nanlalambot at nanghihina ako. Nasamahan pa
po ito ng konting pagkahilo at pagsakit ng tiyan.”

Aggravating and Alleviating Factors – “pagkaconfine ko po dito,

uminom lang po ako ng gamot at ng maraming tubig para maging
mabuti po yung pkiramdam ko, dinadamihan ko din po yung
pagkain ko.”

Client’s Perception – “sabi po ng tatay ko baka daw po dahil sa

pagkain ng scrable at ng ulam na maraming patis ang maari pong
naging dahilan. Sa tingin ko naman po, okay na ang pakiramdam
ko ngayon, wala pong masakit sa akin at hindi na po ako ulet
nagsuka at nagtae.”

E. Past Medical History or Past Health

a. Pediatric / Childhood/ Adult illnesses – the client experienced
colds, cough and fever
b. Injuries or Accidents – None
c. Hospitalizations and Operations – This is the first time the client
was hospitalized. The only reason he goes to hospital is for
check-up or follow-up check up due to his coughs, colds and
fever.
d. Reproductive History – the client has not yet been circumcised.
e. Immunizations
BCG / / at birth / / School entrance
st nd
DPT: / /1 dose / /2 dose / /3rd dose
st nd
OPV: / /1 dose / /2 dose / /3rd dos
AMV / /
TT: / /1st dose / /2nd dose / /3rd dose
th th
/ /4 dose / /5 dose
HPV: / /1st dose / /2nd dose / /3rd dose
Others:
* The father’s client who is a reliable source can’t remember the
immunizations his son had but believed that it is complete*
 F. Family History

50 73, H/W 64, hpn 62, H/W

Mild Stroke

32, H/W 30, H/W

Legend
9, H/W
Male -
8, H/W
Female –

Deceased –

Client/ Patient -
G. Socio-Economic History
Family Member Occupation/ Source Monthly Income
of income

A.M. Francisco Factory Worker P6,000

(Mother)
R. Francisco N/A N/A

H. Psychosocial Assessment
The client is currently in the Early Childhood Stage based on Erikson’s
Psychosocial Development. The present psychological crisis in this stage is
Autonomy vs. Shame & Doubt.

I. Functional Assessment

1. Health-Perception-Health Management Pattern

The client described himself as a healthy person. Playing basketball,
hide and seek, it game, and etc. serves as a form of exercise for his body.
G.J Francisco is fond of eating nutritious foods, unlike the usual kids these
days; the client is far way different from them. For him, eating fruits,
vegetables and fishes are important to maintain a healthy body. At a very
young age, the client seems to have already an idea on maintaining a
balanced diet and a healthy lifestyle.

2. Nutritional-Metabolic Pattern
The client is not fastidious when it comes to choosing foods. G.J.
Francisco thinks that vegetables in the food groups are the most needed to
maintain a healthy mind and body. The client’s favorite are sea foods
especially tilapia, crab as well as shrimps. Moreover, fruits are also part of his
main food groups. Banana, mango, apple and santol are the fruits he wanted
most. As for sauces, the client prefers gravy and Mang Thomas instead of
ketchup which is primarily one of the main sources of vitamins. G.J Francisco
lost his appetite when the client experienced vomiting but then began to eat
again after he was admitted to the hospital.

3. Elimination Pattern
The Client’s excretory pattern in terms of urination is normal. The
client verbalized that “mga tatlo hanggang limang beses po ako umiihi sa
loob ng isang araw.” Before admission, the client experienced a lot of
vomiting and some defecation with watery-like stool. Presently, there are
no changes in his urinary pattern as well as in his bowel movement. G.J
 Francisco is positive for bacterial infection in the stool which can be
considered as a heath threat in his digestive system.

4. Activity-Exercise Pattern
From Monday to Friday, the client is always at school 7am to 3pm.
The very first thing he does after the long hrs at school is eat snacks while
watching television. During afternoon, the client goes outside their house
to play along with his neighbors and cousins. The games they usually play
are patintero, luksong-baka, hide and seek, it game, etc. this kind of
games is already a form of exercise for the client. It contributes a lot in
keeping his body healthy and fit. The client’s current disease does not
affect his cardio-respiratory as well as his musculoskeletal system.

5. Sleep-Rest Pattern
G.J. Francisco has a normal sleep-rest pattern. The client
verbalized that “9 pa lang po ng gabi, pinapatulog na agad ako ni nanay
dahil maaga po ako lagi gumigising, paminsan po ng hapon, pinapatulog
niya din po ako ng mga halos isang oras kapag pagod galling sa iskul.”
Based on the statement, the client’s normal sleeping time is 7-8hrs. The
client’s physical appearance is rested as well as relaxed.

6. Cognitive-Perceptual Pattern
The client’s sensory modes of vision, hearing, touch and smell are
all normal. No presence of cognitive functional disabilities and sensory
deficit. In terms of self-expression, the client express himself trough telling
stories and stating sensible answers to all the questions asked. The
client’s education status is surely something to be proud of; G.J. Francisco
is currently a grade 3 student with honor, specifically the top one of their
batch. There is no presence of disease that affects his mental or sensory
function. The client is negative for any pain at all.

7. Self-Perception-Self-Concept Pattern
There is nothing unusual about the person’s appearance based on
his own description. The client perceived himself as a normal human
being who simply possessed the normal attributes or characteristics of an
8-year old kid. G.J. Francisco is definitely comfortable with his
appearance; he described his feeling state as happy and nothing more
unusual.

8. Role Relationship Pattern

The client described his role as a son who needs to finish his
studies to be able to achieve all of his dreams. One of his ambitions in life
is to be a pilot someday. The client idolized a lot of famous person in our
industry nowadays like Michael Jackson and Marky Cielo. G.J. Francisco
also wants to be a talented and great actor as well as singer and dancer
someday. The client’s important relationship at present is his relationship
 among his family. His major reason for studying hard is to fulfill his goals
in life and to help his family when he grows up.

9. Sexuality-Reproductive Pattern
The client is still a kid and did not experience any circumcision yet.
There are no diseases or dysfunction found in the reproductive system of
the client.

10. Coping-Stress Tolerance Pattern

Every time the client is experiencing problems, he tries to cope up
with it by means of studying. The client’s coping actions is making things
better, not only it affects his problem but also it contributes in the progress
of his studies.

11. Value-Belief Pattern

The client set of values was morally taught by his parent’s
teachings. He believes that education is the key for a successful future
that’s why he is doing everything he can just to maintain his top 1 position
at their school. The client’s religion guides them for sticking as a family.
Every Sunday, their whole family goes to church to attend mass. His being
religious contributes a lot for the betterment of his life. He believes that
God is always there to help them and his family especially in time of
needs. Primarily, the support system that the client find significant is his
whole family.
J. Review of Systems and Physical Examination

System R.O.S/ P.E

1. General Client’s height is 43inches. Temperature is
36°C, Pulse rate is 87bpm and Respiratory
rate is 18cpm.
2. Integument No history of skin disease,
(-)hair loss
(-)changes in the nails
` Client’s vision is normal.
4. Eyes Client doesn’t use eyeglasses. No abnormal
findings are found
Eyes Symmetrical
5.Ears Ears symmetrical
(-)ear pain
6.Nose and Sinuses No obstructions.
(-)discharges.
7.Mouth and Throat (-)hoarseness or voice change
(-)sore throat
8.Neck (+) nape pain
(-) lumps or tender lymph nodes
9.Breast and Axilla Client doesn’t have any history of breast
disease
(-)lump in the breast and axilla portion
10.Respiratory Client doesn’t have any history of lung
disease
(-) chest pain
(-)cough
11.Cardiac Client doesn’t have any history of cardiac
disease.
Normal pulse/heart rate
12.Gastrointestinal Client experienced AGE w/ some DHN, mild
abdominal pain, vomiting and watery-stool.
Presently has a good appetite
13.Urinary Client doesn’t have any history to neurogenic
bladder
(-)incontinence
(-)UTI
14.Genitalia Client is not yet circumcise
(-)pain
(-)discharges
15.Peripheral Vascular (-)coldness and numbness of the extremities
(-) discoloration of the hands and feet.
 16. Musculoskeletal (-)muscle pain
(-)swelling
17.Neurologic No history of seizure disorder and stroke
(-) memory disorders
18.Hematologic (-)excessive bruising
19.Endocrine No abnormal findings were found
20.Psychiatric (-)nervousness
possible depression

III. LABORATORY STUDIES AND DIAGNOSTICS

Procedure and Indication Normal Values/ Actual Findings Nursing

Date Findings Responsibilities
Fecalysis, July Infection RBC: 4.5-5.5 RBC: 0-3/hpf
08, 2009 Pus cells: 0.7- Pus cells: 1-
0.9 3/hpf

IV. NURSING CARE PLAN

CUES NURSING OBJECTIVES PLAN OF RATIONALE EVALUATION

DIAGNOSIS OF CARE INTERVENTIONS SCHEME

S >Diarrhea >At the end >Encourage the >Increase in >

> “Okay na related to of the shift, pt. to fluid fluid intake will Encouraging
po ang parasitic the patient intake by means alleviate the the client is
pakiramdam irritation to will no longer of drinking a lot of client’s present not that
ko, wala na intestinal show signs of water. condition. complex to do
pong mucosa Diarrhea (e.g. >Monitor I & O by > Unusual due to the
gaanong defecation of checking the frequency of client’s
masakit sa watery stool, frequency of his urination and interest in
akin.” As vomiting, urination and defecation making his
verbalized nausea, etc.) defecation as well might be a health better.
by the as the quantity of health threat to >Monitoring
patient. the urine and the patient. I&O needs a
> “Umayos stool. >Keeping the lot of focus in
nap o ang >Doing some environment terms of the
pag-dumi ko health teaching in clean will time interval.
mula ng keeping the decrease the >Health
maconfine patient’s possible teaching is
ako”. As environment sources of very possible
verbalized clean. bacteria. to do; the only
by the >Advising the pt >Hands are difficulty is if
patient. to do hand always used in the pt. will
washing before our everyday apply those
O eating. life which is the teachings
>(-) >Monitor V/S most prone after being
vomiting especially the part of our discharged.
(-) nausea body body that’s >Monitoring
(-) temperature, usually the V/S is always
abdominal body source of a part of
pain temperature germs/bacteria assessing the
(-)DHN might indicate . pt’s health so
infection. >Hyperthermia there’s no
V/S: can be a factor difficulty in
T-36°C of possible doing this at
PR-87bpm disease all.
RR-18cpm caused by
infection.