I.

PATIENT DEMOGRAPHIC PROFILE Name:Stephanie Gerundio Age: 17 yrs old Home Addres: Purok 6, Nage, cebu city Date of Birth: November 30, 2010 Place of Birth: Cebu City Nationality: Filipino HEALTH HISTORY PROFILE A. PAST MEDICAL HISTORY Illness Pneumonia Diarrhea Hemorrhagic fever Otitis Media Malnutrition Anemia Skin infection Chicken pox Measles Mumps Others: Medication

Gender: female

II. 1. Illness Date

Remarks

2. Immunization Immunization BCG Hepatitis B OPV DPT MV Others:

Doses

Dates

Remarks The patient has completed her immunization but cannot remember the exact date that was given to her

3. Hospitalization Date/Year

Hospital

Diagnosis

Duration

3. Injuries/ accidents: Stephanie Gerundio did not get any injuries and was not involved in any kinds of accidents. 4. Transfusion: Stephanie Gerundio did not receive or gave blood in the past. 5. Allergies: Stephanie Gerundio said that she has allergies to grasses B. FAMILY HISTORY(Support with a genogram and limit to two generation if patient can recall)

C.

Social and Personal History 1. Occupation of parents, patients status: Stephanie Gerundio smother is only a housewife while I was not able to ask for the occupation of the father. 2. Number of siblings: Stephanie Gerundio have 5 siblings 3. Birth History: The mother said that there were no complications during birth and the delivery type was a normal delivery or vaginal delivery. 4. Foreign Travel of parents: The parents of Patient did not travel on any foreign place, while in local travel, both of them only traveled around Cebu City 5. Habits of Parents: The father does not smoke and drinks alcohol alcohols beverages occasionally, the mother does not smoke and drink. 6. Diet/Nutrition: Their diet is balance composed of carbohydrates, fibers and proteins. They prefer to eat vegetable and fish rather that pork or any kinds of fatty foods. The serving is adequate to meet the individuals nutritional needs. The family usually serves vegetable once a day, specifically green leafy vegetables or squash , fruits are added occasionally if they have budget, they usually eats fish every day and buys meat if there is extra budget. 7. Type of family: The type of family is the nuclear family which is composed of the father, mother, sons and doughter Brief description of average day: Weekdays

Weekends 7:30 am -8: 30 am Prepares breakfast 8:30 am- 12pm Clean the house, do laundries, prepares lunch 12:00pm- 7:30pm sleep time, doing chores 7:30pm- 7:30pm Prepares dinner, go to sleep

6:30 am -7: 30 am Wakes up, prepares breakfast 7:30 am -12: 00 pm Clean house, go to work, prepare for school 12:00 pm- 1:00 pm Prepares for lunch 1:00 pm- 5:00pm Free hour,, sleep time 5:30 pm- 7:30 pm Prepares dinner, 7:30pm 6:30am Sleep time

D.

REVIEW OF SYSTEMS(for the past 6 months) physical assessment General Weight loss/ weight at birth Fatigue Anorexia Night Sweats Chills Fever Weakness Stephanie Gerundio did experienced fever during the past 3 months Skin Itch Rash Lesion Bruising Bleeding Color Change Stephanie Gerundio did not experience any abnormalities during the past 3 months Pain Discharge Itch Vision Loss Diplopia Excessive tearing Glasses Strabismus Conjunctivitis Date of last exam Stephanie Gerundio did not experience any abnormalities during the past 3 months Earaches Discharge Tinnitus Hearing lost Ear Infection Stephanie Gerundio did not experience any abnormalities during the past 3 months Obstruction Discharge Epistaxis Stephanie Gerundio did not experience any abnormalities during the past 3 months Sore throats Bleeding gums Toothache Tonsillitis Oral thrush Stephanie Gerundio did not experience any abnormalities during the past 3 months Swelling Dysphagia Hoarseness Stiffness Concussion Stephanie Gerundio did not experience any abnormalities during the past 3 months Cough Sputum: Amount and Character Hemoptysis Wheeze Pain on respiration Dyspnea Stephanie Gerundio did not experience any abnormalities during the past 3 months Precordial pain Palpation Dyspnea on Exertion Paroxysmal nocturnal Dyspnea Orthopnea Edema Heart Murmur Thrombophlebitis Claudication

Eyes

Ears

Nose

Throat and Mouth

Neck and Head

Chest

Cardiovascular

Gastrointestinal

Stephanie Gerundio did not experience any abnormalities during the past 3 months Heartburn nausea vomiting Bloating Diarrhea Food Intolerance Excessive gas or indication Constipation Change in Bowel movement Jaundice Melena Hemorrhoids Hernia Stephanie Gerundio experienced changed in bowel movement prior admission Burning on urination Hematuria Dysuria Menarche: Problem with menstruation Stephanie Gerundio did not experience any abnormalities during the past 3 months Joint pains Claudication Muscle Sprain Back pain Edema Stiffness Deformities Stephanie Gerundio did not experience any abnormalities during the past 3 months Numbness Tingling Tremor Fainting Headaches Muscle weakness Ataxia Unconsciousness Paralysis/paresis Memory loss Dizziness Seizure Stephanie Gerundio did not experience any abnormalities during the past 3 months Stephanie Gerundio only experience cough and colds during the past 6 months

Genitourinary

Extremities

Neurology

Others

III.

CURRENT HEALTH PROFILE A. Presenting complains and medical diagnosis to include intervention done prior to hospitalization: Chief Complaint: Duration: Intensity: Frequency: Description: Associated Symptoms: Action Taken: B. Application of the nursing Process 1. Assessment findings(Head to Toe) Vital Signs T: 36.1 P: 92 R: 18 BP: 120/70

Skin: Temperature: the temperature was below 38 c which is normal Color: when observed the skin color was light brown in color Texture: when touched the skin texture was smooth and soft Turgor:no decrease turgor is observed Presence of any lesions: no lesions were present in the body Rashes: no rashes were observe in the body Birthmarks: no birthmarks were observed in the skin Injuries/Scars: no scars were observed in the skin Edema: assessment of edema was not done because the baby was still 3 months Others: HEAD: Hair: Texture: the hair is smooth and firm Distribution: the distribution of the hair in the head is even Presence of: there were no presences of nits, eggs, lice, dandruff, alopecia or hair loss in the head Others: Scalp: Skull: Shape: the scalp when assessed was clean and dry Deformalities: no deformalities observed when palpated Lumps: no lumps were observer on the skull when it was palpated

Tenderness: no tenderness was observed in the skull when palpated Others: Face: Facial Expression: the facial expression of was somewhat tired but she was happy because she can go home already Symmetry: the face was symmetrical with an oval shape Involuntary movements: there were no involuntary movements in the face , head is held still and upright. Edema: no edema was observed Masses: there were no masses found in the face Acne: there was no acne found in the face Warts: there were no warts found in the face Moles: there were no moles found in the face Others: Eyes: Position and alignment: the eyes are symmetrical and are both aligned. Eyebrows: eyebrows are symmetrical. Eyelids: eyelids have transient edema, absence of tears Lacrimal apparatus: was not assessed due to age of the infant Conjunctivas and scleras: sclera and conjunctiva are clear and free of discharges, lesion, redness or lacerations. Iris: the iris was typically round, flat and evenly colored. Pupils: the pupil was round with regular border centered in the iris. In an average size and is symmetrical, the color of the pupils are brown. Others: Ears Symmetry: the ears are symmetrical and in equal size. Hearing: was not assessed due to the age of the infant Nose and Para nasal Sinuses: Symmetry: the nose was symmetrical. Flaring of nostrils: Septum: there were no deviated septum observed in the nose Deformity: there were no deformities in the nose Inflammations: there were no inflammations in the nose Presence of tenderness on the sinuses: was not assessed due to the age of the infant Discharges: there were no discharges present in the nose Mouth: A. Lips: the lips of Stephanie Gerundio are smooth and moist without lesion or swelling with pink color of the lips. B. Buccal Mucosa: the buccal mucosa of Stephanie Gerundio has a pink color with smooth, moist and with no lesions. C. Gums and Teeth: Color: the color or the gums of Stephanie Gerundio l is pinkish while his teeth is color white. Number of teeth present:. has complete number of teeth Presence of Abnormalities: There are no abnormalities observed in the mouth Stephanie Gerundio Others: D. Palate: hard palate of Stephanie Gerundio are present with no signs of abnormalities E. Tongue: the tongue of K Stephanie Gerundio is moist, papillae present; symmetrical appearance. The movement is smooth with a pinkish color. F. Tonsils: The tonsil of Stephanie Gerundio has a color of pink and symmetrical, no exudate, swelling or lesions present. G. Posterior Pharyngeal wall: the throat is normally pink without exudates or lesions. H. Gag Reflex: Gap reflex of Stephanie Gerundio is intact. Others:

Neck: : Symmetrical: the neck is symmetrical with head centered and without bulging masses. Masses: there are no masses observed in the neck of Stephanie Gerundio Lypth Nodes: in the preauricular nodes, postauricular nodes and occipital nodes, there were no swelling or enlargement and no tenderness observed. While in the tonsillar nodes there were still no sweeling, tenderness and harness present. In submandibular nodes and submental nodes, no enlargement or tenderness is present. Superficial nodes, posterior cervical nodes, deep cervical nodes and supraclavicular nodes have no enlargement or tenderness present. Trachea: the trachea of Stephanie Gerundio is in the midline. Thyroid: the landmarks are positioned midline. No enlargements of thyroid present. Others: Lungs/ thorax: Rate: the breath rate or respiratory rate of John Carlo was 57 cycles per minute Symmetrical: the lungs/ thorax of is symmetrical Breath Sounds: Presence of Cough: Stephanie Gerundio was not experiencing cough thus it is non-productive. Others: Cardiovascular: Pulse (site): the pulse rate that I check was the apical pulse Rate: The pulse rate of Stephanie Gerundio was 92 beats per minute. Heart Sounds: the heart sound of Stephanie Gerundio was lab dub Abdomen: Inspection: Shape:the abdomen is prominent in supine position Umbilicus: umbilicus has no discharge, odor, redness and hernia Muscular integrity: the muscle were smooth with no signs of abnormalities Auscultation: Bowel sounds: Bowel sound was normal Palpation: Tenderness: no tenderness was palpated during the test in the abdomen of KerthRussel. Musculoskeletal: A. Back: presence of: there were no presence of dimples, kypthosis, lordosis or scoliosis in the back of Stephanie Gerundio, spine is rounded. B. Joints: full range motion with no swelling, redness, and tenderness C. Muscle: muscles size and strength is adequate for the age of Stephanie Gerundio and is equal bilaterally. D. Extremities: Deformity: no deformities were observed Symmetrical: the extremities are symmetrical Presence of Edema: no edema present Presence of clubbing: no clubbing present in the extremities of John Carlo Others: Neurological Function: Olfactory nerve: he was able to smell and identifies scents Optic: client has a vision of 20/20 Oculomotor, trochlear, abducens: Eyes move in a smooth, coordinated motion in all direction, the eyelids covers about 2 mm of the iris Trigemenal:the temporal and masseter muscles contract bilaterally. Facial: the child smiles frowns, shows teeth, purses lips, raises eyebrows and closes eyes against resistance. Glossopharyngeal, vagus: uvula and soft palate rise bilaterally and symmetrically on phonation.

Spiral accessory: there is symmetrical, strong contraction of the trapezius muscle. Hypoglossal: tongue movements is symmetrical and smooth and bilateral strength is apparent Achilles Reflex: there was no reflex hammer available Speech: the word pronunciation was clear and be heard

Capillary Refill Time: ____Sec Pain Assessment: Pain rating scale in use: Patient was not in pain so pain assessment in not applicable Location: Patient was not in pain so pain assessment in not applicable Quality: Patient was not in pain so pain assessment in not applicable Duration: Patient was not in pain so pain assessment in not applicable Aggravating Factor: Patient was not in pain so pain assessment in not applicable Alleviating Factors: Patient was not in pain so pain assessment in not applicable Genitourinary: Female Genitalia Tanner stage of hair growth and configuration: Hair Growth was observed Presence of lesion: no lesion present Menstruation: Presence of discharges: no discharges were observed said the father Presence of lesion: no lesions were observed in the patient Others:

Lab Result: Date Lab Exam Patient Result Normal Findings Interpretation