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
lawas”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
Drug Allergies: Measles ___ ___ Discoloration of the Gingiva from pink to
dark red, Formation of Masses about 1
“No allergies.” as verbalized by the mother. cm

IV. ASSESSMENT OF SYSTEMS
Objective
General Appearance
Pale, weak, irritable, well-groomed; client
manifest facial grimacing upon movement.
Personal Hygiene/ Habits/ Grooming/ Hair
Hair is well-combed, neat, nails clean and well-
trimmed.
Clothing/ Manner of dress
Dresses neatly and appropriately.
*Note: Mother verbalized complete but no
evidence shown.
V. NUTRITIONAL / METABOLIC PATTERN
Skin color: Fair complexion but pale in
appearance.
Lesions: Red spots distributed all over the
body. Bruise seen on left wrist caused by an IV
insertion and on right knee due to a light bump
Hair Color: Black Texture: Smooth
Lesions: None
Nail Color: Pink nail beds
Daily Food Intake (*Note: Client is supposed
to be in a soft diet but doesn’t want to eat the
food served on the hospital.)
Breakfast: 1 cup rice and viand (specifically
paksiw and sinigang which are his favorites).
Lunch: 1cup rice and viand
Dinner: 1 cup rice and viand
Snacks: 1 pint ice cream and 2-3 pieces of
cookies
Food Supplements / Vitamins Taken:
Fern-C, Cherifer PGM, Herb supplement

Condition: Nails are round, intact, firm, Food Allergies: “No food allergies” as
Immunizations received: smooth and with good capillary refill. verbalized by the mother.

Immunizatio Date Place Oral mucosa: Teeth: Impaired, especially the VI: ELIMINATION
ns Received Received central incisor and the lower molars.
Bowel Habits:
BCG ___ ___  Condition: Oral mucosa is moist. Dental Frequency: Once a day
Carries seen on central upper and lower
DPT ___ ___ incisor, and lower molars. With regards Consistency: Soft
OPV ___ ___ to gum condition, mother states, “Ga-
dugo iyang gums”. Mother added, “Naa Color: Brown
Hepa B ___ ___ ko mga nakit-an na burot sa sulod sa
iyang baba.” Presence of halitosis, Amount: Depending on food intake
Bladder Habits: Smell: Good sense of smell; can identify odors. sucking. Puts developed a mouth and
any objects sense of eye-ear
Frequency: 4 times a day Aids for vision: None into mouth. trust. Child coordinati
Needs are learned to on.
Amount: Depending on fluid intake Aids for hearing: None satisfied love and be Experienc
through loved. ed
Color: Amber straw X. COGNITIVE sucking. separation
anxiety
Ability to express: Speech is clear with when
mother
moderate pace. Responds appropriately to
VII: ACTIVITY-EXERCISE leaves.
topic discussed.Expresses full and free-flowing
thoughts during interview. Toddler Toilet trained. Learned to Egocentric
Daily Activities: Kasagara nako buhaton kay Able to be .
mag-play games sa PSP and computer, watch XI. ROLE-RELATIONSHIP PATTERN control independent Displayed
TV dayon. micturition in decision- static
Ordinal position of client in family: Eldest and making. thinking.
Leisure Activities: “The same lang.” as defecation.
verbalized by the client. Primary caregiver of client: Mother, cousin Identifies Learned how Lack of
Prescho
parent of the to do things reversibilit
Exercise Routine: Walking Other support system: Relatives ol
opposite sex. and solve y.
Child learned basic
VII. SLEEP-REST sexual problems.
identity Has the
Time of Sleep: 8:00 pm-6:00 am through initiative in
awareness of doing things.
Sleep Aids: Cuddled pillow genital area.

Quality: Continuous School- Actively Learned how Able to

participated to do things use
DEVELOPMENTAL MILESTONES (Infant to age
IX. SENSORY-PERCEPTUAL in school well. memory to
Adolescent) activities. Industrious. learn new
Vision: Clear with pupils reactive to light; no concepts.
Psychosex Psychoso Cogniti Able to
reported vision problems.
ual cial ve classify
objects.
Hearing: Client states, “medyo gakabungol- Able to suck. Needs were Manifeste
Infancy Awareness
bungol ko these past few days”. Thumb met and d hand- 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
Likes to hang- Able to problems Total WBC 78.9
body map and then label.) 5.0-10.0
out with express using
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