II.

NURSING PROCESS

A. ASSESSMENT
1. PERSONAL DATA

Patient Exbi is a 12 year old male child , 3rd youngest among 9 siblings,
resides at San Isidro, San Fernando, Pampanga. He is a Filipino citizen, born on
November 5, 2005 at a tertiary hospital (JBLMRH). His mother and father are
both Filipinos and are devoted members of the Roman Catholic Church.
Patient Exbi was admitted January 14, 2018 and was discharged January
18, 2018 with a final diagnosis of Acute Glomerulonephritis.

2. PERTINENT FAMILY HISTORY

Patient Exbi comes from an extended family. His family lives together
under one roof in San Isidro, Pampanga. Unfortunately most of his guardians
died years ago. According to their 3rd eldest, aged 19, his mother died due to her
diabetes mellitus while his father died due to the cancer of bones. Both his
grandparents died and the eldest was not able to recall exactly the specifics.
Their eldest sibling stands as their breadwinner and the caretaker of the family.
Also, the 3rd eldest and the patient were not able to recall the mother’s previous
modes of birth with their siblings.
Patient Exbi lives together with his siblings in a bungalow type of house
that is inadequate in size for them to live in. The house has two parts. One room
where they sleep and another where they do their laundry, cook their food and
where some other things in the house are kept. Their house is supplied with
electricity and a pitcher pump. They also have cellphones, which they utilize for
communicating with their relatives and friends. They live in an environment that is
like a “barrio” where they have close neighbors and a barangay that supervises
the place.
 The family collects water through pitcher pumps, which they use for
bathing, washing their clothes, and dishes. They have mineral water jugs where
they acquire water for dinking.
According to Exbi and the significant other, they drink coffee and eat
pandesal every morning, which is already their breakfast. Their eldest buys their
food in one of their neighborhhod. They usually buy ingredients to cook their
favorite foods such as adobo, sinigang, nilaga as mentioned. Also, they
mentioned that they are fond of eating chips, street foods and instant noodles for
their afternoon snacks. They store their food using plates as their cover
whenever there is left over. They acquire money through their eldest where she
works as a waitress at a fast food chain in Sanfernando, Pampanga.
According to the patient, their family usually consults with those people
who uses their superstitious abilities, such as “hilot”, “mananawas” and etc. They
have cultural beliefs and practices, and they make use of herbal medications
such as bayabas for wound cleaning through decoction of its leaves and boiling
lagundi leaves for cough and colds. Although they believe in such practices, they
try seeking medical consultation from the health center in their barangay, but
most of the time there are no attending health care provider/facilitator. When it
comes to self-medication, they usually make use of Paracetamol for fever.

3. PERSONAL HISTORY

Based on the verbalization of information from the significant other, she

can’t recall the specifics.

4. HISTORY OF PAST ILLNESS

As stated by the client and significant other, he experienced having

mumps, or commonly known as beke. In terms of immunizations, the client is
completely immunized with BCG, DPT, Polio, Measles, Hepa, Influenza, and his
last Tetanus shot. Unfortunately, both the client and SO does not remember the
dates when he had it. Patient Exbi does not have any allergies to drugs,
animals, insects, and other factors, besides having allergic rhinitis due to
environmental agents. About a month ago as stated by the client, he obtained
bruises from playing outside with his friends and a small wound because, as told
by the client, he was running and he didn’t notice a small rock, he stumbled and
fell down with his right knee first. After the incident, the client rushed to go home
to his siblings and got it aided by them. What they did was the basic first aid
technique of cleaning a wound, which was impressive. His older sibling washed
his knee with water and soap, then let it dry first before putting betadine solution
on the wound, which they got from their neighbor.

5. HISTORY OF PRESENT ILLNESS

Chief complaint of the client, as stated: “mainit yung tyan konti.” Also with
signs and symptoms of headache and vomiting. Symptoms started on January
10, 2018, “sa bahay nagstart sumakit yung tyan”, verbalized by the client. And
after a few days, 1/14/18, he was admitted. It suddenly occurred, the number of
times the client’s abdominal area hurts is around 3-5 times a day, lasting about
30s, as stated by the client. The client rated the pain as 7 or 8 out of 10, he then
described the pain as sharp or stabbing pain. It occurred when he was walking
outside with his friends, roaming around their place. Symptoms associated with
the complaint are as follows: headache and stomachache. Factors that
aggravate or alleviate the problem as verbalized by the client and SO, “sa pag
galaw-galaw” and “malikot kasi siya.”

6. PHYSICAL EXAMINATION

Starting from the head, the client’s hair color is black, is thick and long and
distributed evenly around. As inspected and palpated, the scalp has no signs of
any lice, has no presence of any wounds, lacerations, or abrasions. But has
presence of some dandruff. Ears have no presence of any tears, lacerations, or
injuries. It has minimal amount of earwax. Mouth and tongue are moist and pink.
Neck has no presence of any injuries. Peripheral extremities, as inspected and
palpated, are normal. It does not have any signs of injuries. Nails appeared to be
a little dirty and long.

Appearance of the client are as follows: has a small body frame, stands 4
feet 5 inches, weighs around 24.6-24.7kgs, skin appears to be dark, dry, has
good skin turgor, posture of client when sitting is poor, always slacking or in a
slouching position, walks consciously and straight. In terms of hygiene and
grooming, the client is a 6 out of 10. Facial expressions show accordingly to the
mood and situation. Breathing well, respiratory rate is in normal range.

Mental status of the client are as follows: Clients attitude is not that good,
he does not listen when being ask, does not cooperate very well. Mood of the
client is not consistent, there are times that he is upbeat and at times he is
mellow. In terms of the client’s appropriateness to respond, he is not complying
to what is being done. Quality of speech is rated as 6 out of 10. Quantity of
speech is rated as 6.5 out of 10. Clarity is rated as 5 out of 10. Coherence is
rated at 6 out of 10. Vagueness of the client is rated at a staggering 8 out of 10.