COLLEGE OF NURSING

PEDIATRIC ASSESSMENT FORMAT

I.

PATIENT DEMOGRAPHIC PROFILE

Name: C.A
Female

Age: 79

Home address: TabokLamak, Yati, Liloan, Cebu

1936
Place of Birth: Leyte

Date of Birth: March 26,

Religion: Roman Catholic Nationality: Filipino

Information Obtained From: NoretaPalao

3-15
II.

Gender:

Relation:Daughter

Date admitted: 5-

HEALTH HISTORY PROFILE

a. Past Medical History
i. Pediatric Illness
DATE

ILLNESS
Pneumonia
Bronchitis
Tuberculosis
Mumps
Chicken Pox
Measles
Diarrhea
Constipation
Others:
____________

MEDICATION

REMARKS
The client didnt
experience any
illness before.

ii. Immunization
IMMUNIZATION
BCG
Hepatitis B
OPV
DPT
MMR
Others:
____________

DOSES
1
1
2

DATES
The client cannot
recall the dates of
the immunization
given.

REMARKS
The client has not
completed all the
given
immunization.

iii. Hospitalization
DATE

HOSPITAL

DIAGNOSIS
The client cannot
recall the dates of

DURATION

any hospitalization
before.
iv. Injuries and Accidents: The client experienced miscarriage
once before but she couldnt recall the date.
v. Transfusions: The client did not experience any transfusion
procedure especially blood transfusion.
vi. Allergies: The client didnt experience any allergies.

b. Family History:

-deceased

-father

-mother

-spouse

-patient

The client cannot recall due to aging. The client was not accompanied by
her S.O.
Interpretation:
Client C.A. is a seventy nine years old. A resident of Tabok, Lamak, Yati,
Lilo-an, Cebu. She has no occupation. Her husband died due to aging. She

had nine pregnancies and one miscarriage. Both her parents died due to
aging.
c. Social and Personal History:
i. Occupation: The client dont have any occupation.
ii. Number of Children: The client have 9 children.
iii. Military experiences, foreign travel: The client dont experience
any foreign travel.
iv. Habits: The client dont have any vices.
v. Diet: The client has a soft diet.
vi. Type of Family: The client has a single parent family.
vii. Cultural and Religious Beliefs: Roman Catholic
viii. Brief description of average day:
AM
PM
8:00 Waking up
lunch time
8:30-9:45-breakfast , brushes her teeth
brushes her teeth
10:00-11:30- take a bath & dress up
watch tv
2:00-4:00- sleeping time

12:00-12:3012:30-12:3512:35-2:004:00-6:00

watch tv
6:00-6:30
dinner time
6:30-6:35
brushes her teeth
6:40sleeping time

d. Review of Systems. Physical Assessment

General

Skin

Eyes

Weight loss
Fatigue
Night Sweats
Chills
Weakness

Anorexia
Fever

Itch
Rash
Lesions
Bruising
Bleeding
Color change
The client never experienced these
problems.
Pain
Discharge
Itch
Vision Loss
Diplopia
Excessive tearing
Glasses/Contact lens
Date of lass
exam

Ears

Nose

Throat and Mouth

Neck and Head

Chest

Cardiovascular

Gastrointestinal

Genitourinary

Extremities

The client experienced excessive

tearing. The patient use eye glasses.
Earaches
Discharges
Tinnitus
Hearing loss
The client experienced discharges in
her left ear.
Obstruction
Discharges
Epistaxis
The client never experienced these
problems.
Sore throats
Bleeding gums
Toothache
Dentures
The patient never experienced these
problems.
Swelling
Dysphagia
Hoarseness
The client never experienced these
problems.
Cough
Sputum: Amount and
Character
Hemoptysis
Wheeze
Pain on respiration
Dyspnea
The client never experienced these
problems.
Precordial pain
Palpitation
Dyspnea
on Exertion
Paroxysmal nocturnal
Dyspnea
Orthopnea
Edema
Heart murmur
Thrombophlebitis
Claudication
The client never experienced these
problems.
Heartburn
Nausea
Vomiting
Bloating
Diarrhea Food Intolerance
Excessive gas or indication
Constipation
Change in bowel
movement
Jaundice
Bloating
Melena
Hemorrhoids
Hernia
The client experienced nausea,
diarrhea, and change in bowel
movement.
Heartburn
Nausea
Vomiting
Bloating
Diarrhea Food Intolerance
Excessive gas or indication
Constipation
Change in bowel
movement
Jaundice
Bloating
Melena
Hemorrhoids
Hernia
The client experienced dysuria.
Joint pains
Varicose veins
Claudication
Back pain
Edema
Stiffness
Deformities

Endocrine

Neurology

Others

III.

The client had edema in her right foot.

Hot flashes
Hair loss
Temperature
Intolerance
Polydipsia
Goiter
The client never experienced any of
these problems.
Numbness
Tingling
Tremor
Fainting
Headaches
Muscle
weakness
Ataxia
Unconsciousness
Paralysis/Paresis
Memory loss
Dizziness
Seizure
Anxiety
Depression
Sexual
Problems
Insomnia
Nightmares
The client experienced depression.
The client did not experienced any
other problems.

CURRENT HEALTH PROFILE

A. Presenting complaints and medical diagnosis to include intervention
done prior to hospitalization
Chief complaint: The patient experienced nausea and diarrhea.
Duration: The patient had LBM for almost 4 days
Intensity: frequent bowel movement
Frequency: 4-5 times a day
Descriptions: watery mucoid stool
Associated symptoms: The patient felt abdominal pain in epigastric
region
Action taken: her daughter took her to the hospital immediately
Admitting diagnosis: Amoebiasis
Date of admission:May 3, 2015
B. Application of the Nursing Process

1. Assessment Findings (Head to Toe)

Vital Signs
BP: 110/60
Pulse rate: 90 bpm
Respiratory rate: 28 cpm
Head
Hair is dry and well-distributed. Scalp is slightly scaly. Head is
rounded normocephalic and symmetric.

Face
The face of the client appeared smooth and has uniform consistency and with no
presence of nodules or masses. Her facial expression is inappropriate. . Face is not
proportionate and asymmetric.Part of the mouth is slightly elevated.

Eyes
Inner canthus is horizontally slant, no epicanthal folds. Outer canthus aligns with
tips of the pinnas. No swelling, discharge, or lesion of eyelids. Both clients eyes are
cloudy and watery.The Bulbar conjunctiva appeared transparent with few capillaries
event.The sclera appeared white.There is no edema or tearing of the iris and visible.
Pupils are equal, round, and reactive . Eyebrows are symmetrical in shape and
movement.Eyelashes are evenly distributed and curled outward.Client has unequal
vision.

Ears
Top of pinna across the eye occiput line. No unusual structure or markings on the
pinna. There was discharges but there no excess cerumen, lesions, excoriations, or
foreign body in external canal. The patient can answer whispered questions. Auricle
aligns with each other with the corner of each eyes.

Nose and Paranasal sinuses

Nose is midline in face, septum is straight, and nares are patent. No discharge or
tenderness is present. No tenderness palpated over sinuses.

Mouth
The lips of the client are slightly violet, dry, asymmetric and have rough texture.
The client has only one tooth and yellow in color. There are no discoloration of the
enamels, no retraction of gums, pinkishcolor of gums. The buccal mucosa of the
client appeared as uniformly pink.

Neck
Neck is symmetrical with head centered and without bulging masses. The trachea is
midline. There were no masses or lymph nodes palpated. The thyroid gland is not
visible on inspection and the glands ascend during swallowing but are not visible.

Thorax, Lungs, and Abdomen

Respiratory rate, 28 cpm, is abnormal. Breath sounds seem to be louder and clear.
No adventitious sounds were heard. The patient didnt experience Dyspnea.

Cardiovascular
Breasts are flat and symmetrical. The pulse site was heard between the 4 th and 5th
intercostal space, left midclavicular line. Pulse rate is90 bpm, is normal.

Abdomen
The abdomen of the client has an unblemished skin and is uniform in color. The
abdomen has a symmetric contour. There were symmetric movements caused
associated with clients respiration. The jugular veins are not visible. Client
expresses flank pain.

Musculoskeletal
Feet and legs are asymmetric in size, shape, movement and positioning. Extremities
are warm but immobile. Joints are not of full range of motion and there is no
swelling or tenderness.

Neurologic Function
She can identify light touch, dull and sharp sensations. Her speech is unclear. She
cannot move her lower extremities. She has a capillary reflex of two seconds. She is
alert and active, responds semi-appropriately, and relates well with nurse.

Female Genitalia
The female genitalia of the client wasnt assessed because the client doesnt want
to be assessed. We only asked her questions. Client expresses pain in urinating.

Laboratory / Diagnostic Results

Date

Lab Exam
Urinalysis

Patient
Results
color: yellow
appearance:

Normal
Findings
Color: amber
yellow
Appearance:

Interpretation/Signi
ficant
Normal urine is
typically light
yellow and clears

hazy

pH: 7
Protein: trace

Sputum
Exam

Fecalysis

Glucose:
negative
RBC:
numerous/HP
F
WBC: 0-3/HPF
Amorphous
( Materials)
rare
Epithelial
cells: rare
Bacteria : few
Lab.
Diagnosis:
negative AFB
Color: brown
Consistency:
Soft

clear-hazy
Specific
gravity:
1.002-1.030
pH: 5-7
Protein:
negativetrace
Glucose:
negative

Color: brown
Consistency:
soft and
bulky, small,
and dry,
depending on
the diet

Ova and
parasites:
none
Microscopic
examination

Sonographic
Report

Ova &
Parasites:
E.
histolytical /
E. dispar
cyst=1-2/hpf
Other
findings:
Bacteria =
many

Normal
sonogram of
the
gallbladder,

without any
cloudiness.
When the urine
does not have its
characteristic clear
appearance. It is
often referred to as
cloudy, turbid, or
foamy urine.
Cloudy or foamy
urine may occur
occasionally due to
mild dehydration.

Consistency of stool
can vary
considerably in
healthy individuals
depending on their
diets. Mucoid stool
indicates diarrhea.
Thus, individuals
who eat large
amounts of
vegetables will
have looser stools
than individuals
who eat few
vegetables. Many
bacteria in stool
indicate amoebiasis
and may cause
infection.
Parasites or eggs
present in the stool
indicate a parasitic

X-RAY
RESULT:

Impression:
Consider
hepatic
schistosomias
is versus
early cirrhosis
-ascites
-Bilateral
Minimal
Pleural
effusion
Agecompatible
small
anteverted
uterus &
unremarkable
adnexae
Impression:
1.Chronic
inflammatory
process, right
upper lung
suggest
follow up
2. Chilaiditis
syndrome

pancreas ,
spleen,
abdominal
aorta, both
kidney &
urinary
bladder

The lungs
looks normal
in size and
shape, and
the lung
tissue looks
normal. No
growths or
other masses
can be seen
within lungs.
The pleural
spaces also
looks normal.

infection, such
asamoebiasis.
The patient had
infection of
intestine which we
called
schistosomiasis
that was caused by
parasitic worms of
Schistosoma type
or an early cirrhosis
in which the liver
does not function
properly due to
long term damage.

The right upper

lung of the patient
suggest/needs
follow up. The
patient had
Chilaiditis
syndrome that
occurs when bowel
gas is interposed
between liver and
the
hemidiaphragm.

Nursing Diagnosis:
Actual Diagnosis
Deficient fluid volume related to diarrhea as manifested by frequent bowel
movement.
Disturbed physical appearance related to changes in physical appearance (aging) as
manifested by poor eye contact.
Possible feelings of hopelessness related to unknown deteriorating physiologic
condition.

Impaired physical mobility related to pain in lower extremities as manifested by

limited physical activity.
Social isolation related to absence of significant others as manifested by loneliness.

Risk Diagnosis
Risk for infection related to compromised immune system.
Risk for injury related to decreased vision.
Risk for Caregiver Role Strain related to complexity of illness and lack of resources.
Risk for Ineffective Family coping related to emotional conflicts secondary to chronic
illness of parent.
Risk for falls related to physical capability as manifested by increased susceptibly to
falling even with assistance or walker.

2. Drug Study
Omeprazole IV
Definition: it decreases the amount of acid produced in the stomach.
Side effects: fever; cold symptoms such as stuffy nose, sneezing, sore throat;
stomach pain; nausea, vomiting, mild diarrhea; headache.

Metronidazole IV
Definition: used to treat bacterial infections of the vagina, stomach, skin,
joint, and respiratory tract
Side Effects: stomach pain, diarrhea; dizziness, loss of balance; vaginal
itching or discharge; cough, sneezing, runny or stuffy nose; swollen or sore
tongue
Ceftriaxone
Definition: used to treat certain infections caused by bacteria such as
gonorrhea disease, meningitis, and infections of the lungs, ears, skin, urinary
tract, blood, bones, joints, and abdomen.
Side effects: a hard lump where the injection was given; nausea, vomiting,
upset stomach; headache, dizziness, overactive reflexes; pain or swelling in
your tongue; sweating; or vaginal itching or discharge
Salbutamol + Ipratropiumvernevelvlst
Definition: This product is used to treat and prevent symptoms (wheezing and
shortness of breath) caused by ongoing lung disease(chronic obstructive
pulmonary disease- COPD which includes bronchitis and emphysema).

Side effects: headache, dizziness, nausea, dry mouth, shaking (tremors), or

nervousness.

Case Study
of
Group 4
Amoebiasis
Group members: