Pedia at

XAVIER UNIVERSITY
YEAR
ATENEO DE CAGAYAN
COLLEGE OF NURSING Down syndrome
NCM 109 RLE IV. CURRENT MEDICATIONS
Mitral Valve Prolapse Drug Dose/Frequency/Route Indication
PEDIATRIC ASSESSMENT TOOL
(December 3, 2019) Dengue 2007 Albuterol Nebulizer q 8 Asthma
I. GENERAL INFORMATION (Salbutamol)
Name: H. G. Contreras Age: 13 Locked knees 2012
Birthday: September 18, 2006 Birthplace: Sinupret 1 tab TID po Sinusitis
Glaucoma 2019
Sex: Female Religion: R. Catholic
Address: San Agustin Homes, CDOC Cefuroxime 750 mg q 8 po Respiratory tract
Current Educational Level: SPED student III. FAMILIAL RISK FACTORS infections
Informant: M. Contreras Relation: mother (Check all that apply & indicate which side: Maternal/Paternal) Drug Allergies no noted drug allergies
Admission Date: December 3, 2019 Time: 9:11 am
/ Hypertension (Both)
Chief complaint upon admission: persistent cough, fever
Attending physician: Dr. Dela Cerna, MD
Diagnosis/impression pediatric community acquired pneumonia Tuberculosis V. INFANT DATA
(moderate risk); Down syndrome; mitral valve prolapse Actual Date of Delivery: ______________ Time: ______
Cerebrovascular accident/Stroke Type of Delivery: _______________________________
II. HISTORY OF PRESENT ILLNESS: Birth date ____________________________________
6 mos PTA: cough, given amoxicillin Place of Birth _________________________________
/ Diabetes Mellitus (Both) Sex _________________________________________
2 days PTA: persistent cough
Weight _______________________________________
Night PTA: persistent cough with fever Head Circumference ____________________________
Kidney Disease Chest Circumference ___________________________
Upon assessment: Abdominal Circumference _______________________
Vital signs: HR 82 bpm RR 40 BP 110/60 mmHg Temp 35.8 C Length ______________________________________
Heart Disease Difficulty at Birth _______________________________
O2 Sat 92% Height 137.32 cm Weight 35.5 kg BMI 16.44
Child feeding __________________________________
Interpret: normal
/ Cancer (Paternal)
Epilepsy VI. ASSESSMENT OF SYSTEMS

General Appearance
Mental Illness Personal Hygiene/Habits pt is assisted by family for hygienic needs
Grooming/Hair hair is tied in a braid, messy
Clothing/Manner of Dress clothing is appropriate for her environment
II. PAST CHILD ILLNESS/MEDICAL/SURGICAL HISTORY
Others: (Specify) ___________________________
Iii. Nutritional/Metabolic Pattern Quality altered during hospitalization; Fowler’s position, O2
i. Respiration medication, pillows as sleeping aids
Skin color fair Lesions none
Objective Hair: Color black Texture rough due to not being able to bathe vii. Sensory-Perceptual
Respiratory Rate 32 Depth shallow Symmetry symmetrical Lesion none Nail Color colorless
Use of accessory muscles none Nasal Flaring none Condition oral mucosa large and fissured tongue, cracked lips Vision existing condition of glaucoma
Breath sounds fine crackles upon auscultation Teeth not properly aligned Hearing some degree of hearing loss due to accumulation of fluid
Cyanosis no cyanosis Clubbing of fingers no clubbing Daily Food Intake Smell no noted problems in smell
Sputum characteristics yellowish white Breakfast rice with chicken soup Aids of vision none
Others Lunch rice with vegetables Aids for hearing none
Subjective Dinner porridge
Dyspnea related to Snacks skyflakes
Cough/sputum yellowish white Food supplementary/ Vitamins vitamin C viii. Mental Status
Food allergies no noted food allergies
History of: Oriented __________ Disoriented ___________
Bronchitis none Asthma none Tuberculosis none iv. Elimination Time _____ Place _____ Person _____
Use of respiratory aids none O2 therapy none _____ Alert _____ Combative _____ Drowsy
Others/comments nebulized and administered O2 during Bowel habits: _____ Stuporous _____ Comatose _____ Lethargic
hospitalization Frequency four times Pupil size/Reaction not examined
Consistency firm Right___________________ Left ________________
ii. Circulation Color brown Posturing sitting with a posterior pelvic tilt, trunk rounded and head
Amount moderate resting on the shoulders
Subjective Constipation none noted Speech Impairment difficulty in speaking and in articulating
Ankle/leg edema no edema Bladder habits: Frequency six times Ability to express no response to communication methods
Extremities: Numbness none Tingling none Amount moderate Others ______________________________________
Others/comments: _____________________________ Color yellowish
BP: R: Lying _____________ Sitting 108/60 mmHg Others pt wears an adult diaper
L: Lying _____________ Sitting _____________ VII. PAIN/COMFORT
Heart sounds: Rate 122 bpm Rhythm affected by MVP v. Activity-Exercise Precipitating none noted
Pulse: Carotid _____ Radial _____ Popliteal _____ Quality of Pain ________________________________
Temporal _____ Femoral _____ Dorsalis Pedis _____ Daily activities goes to a SPED school near her home Radiating at _______________ Severity ___________
Capillary refill <2 secs Color pink Leisure activities watching TV, plays with parents Time (Onset, Frequency, Duration)
Cyanosis/Pallor no cyanosis, slight pallor Exercise routine ambulates for 10-20 mins outside the house ____________________________________________
Varicosities present on the lower side of the face Objective data (S/sx) __________________________
Nail beds pink vi. Sleep-Rest
Mucous membranes pink and moist
Others/comments _____________________________
Time of sleep 10 pm to 8 am
Sleep aids pillow
X. DEVELOPMENTAL MILESTONES A. CBC (12/3)
(Indicate client’s age)
Age Psychosexual Psychosocial Cognitive TEST NORMAL RESULTS UNIT
VALUES
School-age Phallic stage, Mentally at the Preoperational
fixation on anal autonomy vs stage WBC 5.0-10.0 6.7 x103/uL
stage shame and
doubt stage RBC 3.69-5.90 4.44 x106/uL
Hematocrit 37.0-47.0 37.9 %
Hemoglobin 12.0-16.0 12.1 g/uL
MCV 82.0-98.0 85 fL
XI. BODY MAP. (Illustrate in the body map how your patient looks like
e.g. tubes inserted, bruises, surgical incisions, physical abnormalities, MCH 27.0-31.0 27.3 pg
affected areas. Mark with a small “x” where it is located or draw it on
the body map and the label.) MCHC 31.5-35.0 32.0 g/dL
Describe affected areas:
RDW 11.5-14.5 11.1 %
_______________________________________________________
_______________________________________________________
Platelet Count 150-400 262 K/uL
VIII. ROLE-RELATIONSHIP PATTERN _________________________
Ordinal position of client in the family second/youngest child DIFFERENTIAL COUNT
Primary caregiver of the client mother
Other support system of the client elder sister
Neutrophils 37-72 79 %
IX. SAFETY
Lymphocytes 20-50 13 %
Allergies/sensitivity no noted allergies
Reaction no noted allergic reaction
Monocytes 8-14 7 %
Blood transfusion/number none When none
History of accidental injuries no accidental injuries Eosinophils 1.0--3.0 1 %
Fractures/dislocations no fractures, dislocations
Back problems muscles and ligaments supporting the neck is weak Basophils 0.0-2.0 0 %
and loose; sits down with posterior pelvic tilt, trunk rounded and head
resting on shoulders XII. IMMUNOLOGY
Changes in moles no change Enlarged nodes no enlarged nodes
Unusual bleeding none Prosthesis none
HBsAg
LABORATORY/DIAGNOSTIC RESULTS (include date & interpret
results.) HIGHLIGHT the ABNORMAL FINDINGS.
B. X-RAY (12/3)
Diagnosis: Bilateral pneumonia (chest xray)
XIII. IMMUNIZATIONS RECEIVED
Immunization Date Received Place Received
measles 2018
Other relevant information:

_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
__________________________________________________
XAVIER UNIVERSITY
YEAR
ATENEO DE CAGAYAN
COLLEGE OF NURSING Down syndrome
NCM 109 RLE IV. CURRENT MEDICATIONS
Mitral Valve Prolapse Drug Dose/Frequency/Route Indication
PEDIATRIC ASSESSMENT TOOL
(December 8, 2019) Dengue 2007 Spironolactone 250 mg 1 tab BID diuretic
III. GENERAL INFORMATION
Name: H. G. Contreras Age: 13 Locked knees 2012 Procaterol 8 ml BID po asthma
Birthday: September 18, 2006 Birthplace:
Glaucoma 2019 K lyte 1 tab q 6 po potassium deficiency
Address: San Agustin Homes, CDOC
Current Educational Level: SPED student III. FAMILIAL RISK FACTORS Calcium carbonate 1 tab BID po calcium deficiency
Informant: M. Contreras Relation: mother (Check all that apply & indicate which side: Maternal/Paternal)
Albuterol nebulizer q 8 asthma
Admission Date: December 3, 2019 Time: 9:11 am (Salbutamol)
Hypertension (Both)
Chief complaint upon admission: persistent cough, fever
Attending physician: Dr. Dela Cerna, MD Hydrocortisone 140 mg IV q 6 adrenocortical
Diagnosis/impression pediatric community acquired pneumonia Tuberculosis deficiency
(moderate risk); Down syndrome; mitral valve prolapse
Sinupret 1 tab TID po sinusitis
Cerebrovascular accident/Stroke
IV. HISTORY OF PRESENT ILLNESS:
Cefuroxime 750 mg q 8 po respiratory tract
6 mos PTA: cough, given amoxicillin
Diabetes Mellitus (Both) infections
Night PTA: persistent cough with fever Levopront 7.5 ml TID cough
Kidney Disease
Upon assessment: Azithromycin 500 mg ½ tab pneumonia
Vital signs: HR 122 bpm RR 32 BP 108/60 mmHg Temp 35.8 C Heart Disease Furosemide 20 mg IV q 8 loop diuretic
O2 Sat 97% Height 147.32 cm Weight 35.5 kg BMI 16.44
Interpret: normal
Captopril 25 mg 1 tab PO OD
Cancer (Paternal)
Drug Allergies no noted drug allergies
Epilepsy
Mental Illness V. INFANT DATA

Actual Date of Delivery: ______________ Time: ______
II. PAST CHILD ILLNESS/MEDICAL/SURGICAL HISTORY Type of Delivery: _______________________________
Others: (Specify) ___________________________ Birth date ____________________________________
Place of Birth _________________________________
Sex _________________________________________ Ankle/leg edema no edema Constipation none noted
Weight _______________________________________ Extremities: Numbness none Tingling none Bladder habits: Frequency six times
Head Circumference ____________________________ Others/comments: _____________________________ Amount moderate
Chest Circumference ___________________________
BP: R: Lying _____________ Sitting 108/60 mmHg Color yellowish
Abdominal Circumference _______________________
Length ______________________________________ L: Lying _____________ Sitting _____________ Others pt wears an adult diaper
Difficulty at Birth _______________________________ Heart sounds: Rate 122 bpm Rhythm affected by MVP
Child feeding __________________________________ Pulse: Carotid _____ Radial _____ Popliteal _____ v. Activity-Exercise
Temporal _____ Femoral _____ Dorsalis Pedis _____
Capillary refill <2 secs Color pink Daily activities goes to a SPED school near her home
Cyanosis/Pallor no cyanosis, slight pallor Leisure activities watching TV, plays with parents
VI. ASSESSMENT OF SYSTEMS Varicosities present on the lower side of the face Exercise routine ambulates for 10-20 mins outside the house
General Appearance Nail beds pink
Personal Hygiene/Habits pt is assisted by family for hygienic needs Mucous membranes pink and moist vi. Sleep-Rest
Grooming/Hair hair is tied in a braid, messy Others/comments _____________________________
Iii. Nutritional/Metabolic Pattern
Sleep aids pillow
i. Respiration
Quality altered during hospitalization; Fowler’s position, O2
Skin color fair Lesions none medication, pillows as sleeping aids
Objective Hair: Color black Texture rough due to not being able to bathe
Respiratory Rate 32 Depth shallow Symmetry symmetrical Lesion none Nail Color colorless vii. Sensory-Perceptual
Use of accessory muscles none Nasal Flaring none Condition oral mucosa large and fissured tongue, cracked lips
Breath sounds fine crackles upon auscultation Teeth not properly aligned
Vision existing condition of glaucoma
Cyanosis no cyanosis Clubbing of fingers no clubbing Daily Food Intake
Hearing some degree of hearing loss due to accumulation of fluid
Sputum characteristics yellowish white Breakfast rice with chicken soup
Smell no noted problems in smell
Others Lunch rice with vegetables
Aids of vision none
Subjective Dinner porridge
Aids for hearing none
Dyspnea related to Snacks skyflakes
Cough/sputum yellowish white Food supplementary/ Vitamins vitamin C
viii. Mental Status
History of:
Bronchitis none Asthma none Tuberculosis none
Oriented __________ Disoriented ___________
Use of respiratory aids none O2 therapy none iv. Elimination
Time _____ Place _____ Person _____
Others/comments nebulized and administered O2 during
_____ Alert _____ Combative _____ Drowsy
hospitalization Bowel habits: _____ Stuporous _____ Comatose _____ Lethargic
Frequency four times Pupil size/Reaction not examined
ii. Circulation Consistency firm Right___________________ Left ________________
Color brown Posturing sitting with a posterior pelvic tilt, trunk rounded and head
Subjective Amount moderate resting on the shoulders
Speech Impairment difficulty in speaking and in articulating
Ability to express responded to some communication methods like IX. SAFETY
grunting Allergies/sensitivity no noted allergies
Others ______________________________________ Reaction no noted allergic reaction
History of accidental injuries no accidental injuries
VII. PAIN/COMFORT Fractures/dislocations no fractures, dislocations
Precipitating none noted Back problems muscles and ligaments supporting the neck is weak
Quality of Pain ________________________________ and loose; sits down with posterior pelvic tilt, trunk rounded and head
Radiating at _______________ Severity ___________ resting on shoulders
Time (Onset, Frequency, Duration) Changes in moles no change Enlarged nodes no enlarged nodes
____________________________________________ Unusual bleeding none Prosthesis none
Objective data (S/sx) __________________________ XII.
X. DEVELOPMENTAL MILESTONES
results.) HIGHLIGHT the ABNORMAL FINDINGS
Age Psychosexual Psychosocial Cognitive U/A (12/4)

fixation on anal autonomy vs stage Characteristics
stage shame and
doubt stage Color Straw
Transparency Clear
Specific gravity 1.025
pH 5.0
XI. BODY MAP. (Illustrate in the body map how your patient looks like
e.g. tubes inserted, bruises, surgical incisions, physical abnormalities, Sugar -
the body map and the label.) Protein -
WBC 11 (0-11)
_______________________________________________________
_______________________________________________________ RBC 11 (0-11)
_________________________
VIII. ROLE-RELATIONSHIP PATTERN Epithelial cells Moderate
Ordinal position of client in the family second/youngest child
Primary caregiver of the client mother Bacteria Moderate
Spectral and Color Flow Doppler Calcium (Ionized) 0.9 1.13-1.32 mmol/L
C. X-RAY
Potassium 2.80 3.5-5 mmol/L
Max Velocity Peak Gradient
mmHg
Aortic 1.02 4.2

Others XIII. IMMUNIZATIONS RECEIVED
Pulmonic 1.15 5.3
2D Echocardiography (12/6/19)
PA Pressure PAT= 99 msecs
Quantitative Mitral 70%/81 mmHg regurgitation
Normal Range Descending Aorta 9.1 mmHg

LV (ed) 4.32 3.7-4.8
LV (es) 2.45 Qualitative Other relevant information:

● Situs solitus _______________________________________________________
LA (es) 3.7 2.65-3.5
● Atrioventricular and pulmonary venous connection _______________________________________________________
RA (es) ● Intact interatrial and interventricular septum _______________________________________________________
● Thickened prolapsing, coaptating anterior mitral valve with _______________________________________________________
Aorta 1.97 2.4-3.05 severe mitral regurgitation fraction of 70%, max gradient __________________________________________________
112 mmHg
PA ● Mild tricuspid regurgitation with max gradient 16 mmHg
● No coarcitation of aorta XAVIER UNIVERSITY
IVS (ed) 0.84 0.8-1.0 ● LA enlargement ATENEO DE CAGAYAN
● Left sided aortic arch COLLEGE OF NURSING
IVS (es) 0.94
● Good biventricular contractility NCM 109 RLE
LVPW (ed) 1.03 0.8-1.1 ● No pericardial effusion
Diagnosis: PEDIATRIC ASSESSMENT TOOL
LVPW (es) 0.8 MVP with severe mitral regurgitation; LA enlargement (December 9, 2019)
V. GENERAL INFORMATION
Ejection Fraction 57% 55-0.77 Chemistry (12/7) Name: H. G. Contreras Age: 13
Birthday: September 18, 2006 Birthplace:
FS% 30% 28-4.2
Range Sex: Female Religion: R. Catholic
Address: San Agustin Homes, CDOC
Current Educational Level: SPED student (Check all that apply & indicate which side: Maternal/Paternal)
Albuterol nebulizer q 8 asthma
Informant: M. Contreras Relation: mother (Salbutamol)
/ Hypertension (Both)
Admission Date: December 3, 2019 Time: 9:11 am
Chief complaint upon admission: persistent cough, fever Hydrocortisone 140 mg IV q 6 adrenocortical
Attending physician: Dr. Dela Cerna, MD Tuberculosis deficiency
Diagnosis/impression pediatric community acquired pneumonia
(moderate risk); Down syndrome; mitral valve prolapse Sinupret 1 tab TID po sinusitis
VI. HISTORY OF PRESENT ILLNESS: Cefuroxime 750 mg q 8 po respiratory tract

/ Diabetes Mellitus (Both) infections
2 days PTA: persistent cough Levopront 7.5 ml TID cough
Night PTA: persistent cough with fever Kidney Disease
Azithromycin 500 mg ½ tab pneumonia
Upon assessment:
Heart Disease Furosemide 20 mg IV q 8 loop diuretic
Vital signs: HR 116 RR 28 BP 90/60 Temp 36
O2 Sat 93% Height_____ Weight_____ BMI_____
Interpret: normal / Cancer (Paternal)
Omeprazole 1 tab epigastric pain
Epilepsy Drug Allergies no noted drug allergies
Mental Illness
V. INFANT DATA
II. PAST CHILD ILLNESS/MEDICAL/SURGICAL HISTORY Others: (Specify) ___________________________ Actual Date of Delivery: ______________ Time: ______
Type of Delivery: _______________________________
Birth date ____________________________________
Place of Birth _________________________________
YEAR
Sex _________________________________________
Weight _______________________________________
Down syndrome IV. CURRENT MEDICATIONS Head Circumference ____________________________
Chest Circumference ___________________________
Mitral Valve Prolapse Drug Dose/Frequency/Route Indication Abdominal Circumference _______________________
Length ______________________________________
Dengue 2007 Spironolactone 250 mg 1 tab BID diuretic Difficulty at Birth _______________________________
Child feeding __________________________________
Locked knees 2012 Procaterol 8 ml BID po asthma
Glaucoma 2019 K lyte 1 tab q 6 po potassium deficiency
Calcium carbonate 1 tab BID po calcium deficiency VI. ASSESSMENT OF SYSTEMS

III. FAMILIAL RISK FACTORS
General Appearance Others/comments _____________________________
Personal Hygiene/Habits pt is assisted by family for hygienic needs Time of sleep 10 pm to 8 am
Grooming/Hair hair is tied in a braid, messy Iii. Nutritional/Metabolic Pattern Sleep aids pillow
Clothing/Manner of Dress clothing is appropriate for her environment Quality altered during hospitalization; Fowler’s position, O2
Skin color fair Lesions none medication, pillows as sleeping aids
i. Respiration Hair: Color black Texture rough due to not being able to bathe
Lesion none Nail Color colorless vii. Sensory-Perceptual
Objective Condition oral mucosa large and fissured tongue, cracked lips
Respiratory Rate 28 Depth shallow Symmetry symmetrical Teeth not properly aligned Vision existing condition of glaucoma
Use of accessory muscles none Nasal Flaring present Daily Food Intake Hearing some degree of hearing loss due to accumulation of fluid
Breath sounds fine crackles upon auscultation Breakfast Smell no noted problems in smell
Cyanosis no cyanosis Clubbing of fingers no clubbing Lunch Aids of vision none
Sputum characteristics yellowish white Dinner Aids for hearing none
Others Snacks
Subjective Food supplementary/ Vitamins vitamin C
Dyspnea related to Food allergies no noted food allergies viii. Mental Status
Cough/sputum yellowish white
Oriented _pt is oriented_______ Disoriented ___________
History of: iv. Elimination Time _____ Place _____ Person _____
Bronchitis none Asthma none Tuberculosis none _____ Alert _____ Combative _____ Drowsy
Use of respiratory aids none O2 therapy none Bowel habits: _____ Stuporous _____ Comatose _____ Lethargic
Others/comments none Frequency zero Pupil size/Reaction not examined
ii. Circulation Consistency none Right___________________ Left ________________
Color none Posturing sitting with a posterior pelvic tilt, trunk rounded and head
Subjective Amount none resting on the shoulders
Ankle/leg edema no edema Constipation none noted Speech Impairment difficulty in speaking and in articulating
Extremities: Numbness none Tingling none Bladder habits: Frequency once Ability to express responded to some communication methods like
Others/comments: _____________________________ Amount moderate grunting
BP: R: Lying _____________ Sitting 90/60 mmHg Color yellowish Others ______________________________________
L: Lying _____________ Sitting _____________ Others pt wears an adult diaper
Heart sounds: Rate 116 bpm Rhythm affected by MVP
Pulse: Carotid _____ Radial _____ Popliteal _____ v. Activity-Exercise VII. PAIN/COMFORT
Temporal _____ Femoral _____ Dorsalis Pedis _____ Precipitating increased acid secretion
Capillary refill <2 secs Color pink Daily activities goes to a SPED school near her home Quality of Pain Acute_________________________
Cyanosis/Pallor no cyanosis, slight pallor Leisure activities watching TV, plays with parents Radiating at _Abdomen______________ Severity ___________
Varicosities present on the lower side of the face Exercise routine ambulates for 10-20 mins outside the house Time (Onset, Frequency, Duration)
Nail beds pink ____________________________________________
Mucous membranes pink and moist vi. Sleep-Rest Objective data (S/sx) __________________________
X. DEVELOPMENTAL MILESTONES (none)
Age Psychosexual Psychosocial Cognitive
fixation on anal autonomy vs stage
stage shame and
doubt stage
XI. BODY MAP. (Illustrate in the body map how your patient looks like Other relevant information:
e.g. tubes inserted, bruises, surgical incisions, physical abnormalities, _______________________________________________________
affected areas. Mark with a small “x” where it is located or draw it on _______________________________________________________
the body map and the label.) _______________________________________________________
Describe affected areas: _______________________________________________________
__IV line hooked to dorsal area of left hand. Venipuncture site on right __________________________________________________
antecubital
fossa.__________________________________________________
VIII. ROLE-RELATIONSHIP PATTERN _______________________________________________________
Ordinal position of client in the family second/youngest child ____________________________
IX. SAFETY
Fractures/dislocations no fractures, dislocations
XAVIER UNIVERSITY
Back problems muscles and ligaments supporting the neck is weak
ATENEO DE CAGAYAN
and loose; sits down with posterior pelvic tilt, trunk rounded and head
COLLEGE OF NURSING
resting on shoulders
XII. NCM 109 RLE
Changes in moles no change Enlarged nodes no enlarged nodes
Unusual bleeding none Prosthesis none
results.) HIGHLIGHT the ABNORMAL FINDINGS PEDIATRIC ASSESSMENT TOOL
(December 10, 2019)
VII. GENERAL INFORMATION
Locked knees 2012 Spironolactone 250 mg 1 tab BID diuretic
Name: H. G. Contreras Age: 13
Birthday: September 18, 2006 Birthplace: Glaucoma 2019 Procaterol 8 ml BID po asthma
Address: San Agustin Homes, CDOC K lyte 1 tab q 6 po potassium deficiency
Current Educational Level: SPED student III. FAMILIAL RISK FACTORS
Informant: M. Contreras Relation: mother (Check all that apply & indicate which side: Maternal/Paternal) Calcium carbonate 1 tab BID po calcium deficiency
Admission Date: December 3, 2019 Time: 9:11 am / Hypertension (Both)
Chief complaint upon admission: persistent cough, fever Albuterol nebulizer q 8 asthma
(Salbutamol)
Attending physician: Dr. Dela Cerna, MD
Tuberculosis
Diagnosis/impression pediatric community acquired pneumonia Hydrocortisone 140 mg IV q 6 adrenocortical
(moderate risk); Down syndrome; mitral valve prolapse deficiency
VIII. HISTORY OF PRESENT ILLNESS: Sinupret 1 tab TID po sinusitis
/ Diabetes Mellitus (Both) Cefuroxime 750 mg q 8 po respiratory tract
Night PTA: persistent cough with fever infections
Kidney Disease
Levopront 7.5 ml TID cough
Upon assessment:
Vital signs: HR_109_ RR 27 BP 110/60 Temp 36.5 Heart Disease Azithromycin 500 mg ½ tab pneumonia
O2 Sat 97% Height_____ Weight_____ BMI_____
Interpret: normal Furosemide 20 mg IV q 8 loop diuretic
/ Cancer (Paternal)
Epilepsy Drug Allergies no noted drug allergies
Mental Illness
V. INFANT DATA
II. PAST CHILD ILLNESS/MEDICAL/SURGICAL HISTORY Actual Date of Delivery: ______________ Time: ______
Others: (Specify) ___________________________
Type of Delivery: _______________________________
Birth date ____________________________________
YEAR Place of Birth _________________________________
Sex _________________________________________
Down syndrome Weight _______________________________________
IV. CURRENT MEDICATIONS Head Circumference ____________________________
Mitral Valve Prolapse Chest Circumference ___________________________
Drug Dose/Frequency/Route Indication Abdominal Circumference _______________________
Dengue 2007 Length ______________________________________
Difficulty at Birth _______________________________
Child feeding __________________________________ Pulse: Carotid _____ Radial _____ Popliteal _____
Temporal _____ Femoral _____ Dorsalis Pedis _____ v. Activity-Exercise
Capillary refill <2 secs Color pink
Cyanosis/Pallor no cyanosis, slight pallor Daily activities goes to a SPED school near her home
VI. ASSESSMENT OF SYSTEMS Varicosities present on the lower side of the face Leisure activities watching TV, plays with parents
General Appearance Nail beds pink Exercise routine ambulates for 10-20 mins outside the house
Personal Hygiene/Habits pt is assisted by family for hygienic needs Mucous membranes pink and moist
Grooming/Hair hair is tied in a braid, messy Others/comments _____________________________ vi. Sleep-Rest
Iii. Nutritional/Metabolic Pattern
i. Respiration
Sleep aids pillow
Skin color fair Lesions none Quality altered during hospitalization; Fowler’s position, O2
Objective Hair: Color black Texture rough due to not being able to bathe medication, pillows as sleeping aids
Respiratory Rate 27 Depth shallow Symmetry symmetrical Lesion none Nail Color colorless
Use of accessory muscles none Nasal Flaring none Condition oral mucosa large and fissured tongue, cracked lips vii. Sensory-Perceptual
Breath sounds fine crackles upon auscultation Teeth not properly aligned
Cyanosis no cyanosis Clubbing of fingers no clubbing Daily Food Intake
Vision existing condition of glaucoma
Sputum characteristics yellowish white Breakfast
Hearing some degree of hearing loss due to accumulation of fluid
Others Lunch
Smell no noted problems in smell
Subjective Dinner
Aids of vision none
Dyspnea related to Snacks
Aids for hearing none
Cough/sputum yellowish white Food supplementary/ Vitamins vitamin C
History of: viii. Mental Status
Bronchitis none Asthma none Tuberculosis none
Use of respiratory aids none O2 therapy none iv. Elimination
Oriented Oriented Disoriented ___________
Others/comments nebulized and administered O2 during
Time _____ Place _____ Person _____
hospitalization Bowel habits: _____ Alert _____ Combative _____ Drowsy
Frequency zero _____ Stuporous _____ Comatose _____ Lethargic
ii. Circulation Consistency none Pupil size/Reaction not examined
Color none Right___________________ Left ________________
Subjective Amount none Posturing sitting with a posterior pelvic tilt, trunk rounded and head
Ankle/leg edema no edema Constipation none resting on the shoulders
Extremities: Numbness none Tingling none Bladder habits: Speech Impairment difficulty in speaking and in articulating
Others/comments: _____________________________ Frequency none Ability to express responded to some communication methods like
BP: R: Lying _____________ Sitting 110/60 mmHg Amount none grunting
L: Lying _____________ Sitting _____________ Color none Others ______________________________________
Heart sounds: Rate 109 bpm Rhythm affected by MVP Others pt wears an adult diaper
VII. PAIN/COMFORT Fractures/dislocations no fractures, dislocations
Precipitating none noted Back problems muscles and ligaments supporting the neck is weak
Quality of Pain ________________________________ and loose; sits down with posterior pelvic tilt, trunk rounded and head
Radiating at _______________ Severity ___________ resting on shoulders
Time (Onset, Frequency, Duration) Changes in moles no change Enlarged nodes no enlarged nodes
____________________________________________ Unusual bleeding none Prosthesis none
Objective data (S/sx) __________________________
X. DEVELOPMENTAL MILESTONES
Age Psychosexual Psychosocial Cognitive
XII.
fixation on anal autonomy vs stage LABORATORY/DIAGNOSTIC RESULTS (include date & interpret
stage shame and results.) HIGHLIGHT the ABNORMAL FINDINGS
doubt stage
Chemistry (12/10)
Range
XI. BODY MAP. (Illustrate in the body map how your patient looks like Calcium 1.13-1.32 mmol/L
e.g. tubes inserted, bruises, surgical incisions, physical abnormalities, (Ionized)
the body map and the label.) Potassium 4.2 3.5-5 mmol/L
Venipuncture site on right antecubital
fossa.__________________________________________________
_______________________________________________________
VIII. ROLE-RELATIONSHIP PATTERN ______________________________ Immunization Date Received Place Received
Ordinal position of client in the family second/youngest child
IX. SAFETY
Other relevant information:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
__________________________________________________

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XAVIER UNIVERSITY

Epilepsy VI. ASSESSMENT OF SYSTEMS

Hematocrit 37.0-47.0 37.9 %

Hemoglobin 12.0-16.0 12.1 g/uL

XIII. IMMUNIZATIONS RECEIVED

Immunization Date Received Place Received

Other relevant information:

Mental Illness V. INFANT DATA

School-age Phallic stage, Mentally at the Preoperational

Specific gravity 1.025

Aortic 1.02 4.2

Quantitative Mitral 70%/81 mmHg regurgitation

Normal Range Descending Aorta 9.1 mmHg

LV (es) 2.45 Qualitative Other relevant information:

VI. HISTORY OF PRESENT ILLNESS: Cefuroxime 750 mg q 8 po respiratory tract

Glaucoma 2019 K lyte 1 tab q 6 po potassium deficiency

Calcium carbonate 1 tab BID po calcium deficiency VI. ASSESSMENT OF SYSTEMS

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