I.

Patient’s Demographic Profile

Name: Mannylyn Pedes Mejica
Age: 8 years old
Sex: Female
Occupation: None
Civil Status: Single
Address: Tangbo, Arteche, E. Samar
Religion: Roman Catholic
Educational Attainment: Elem. Level
Date of Birth: September 28, 2011
Date of Admission: December 11, 2019
Time of Admission: 03:55PM
Nationality: Filipino
Admitting Diagnosis: UTI
Attending Physician: Dr.
Father’s Name: Emmanuel Mejica
Mother’s Name: Babylyn Pedes
Source of Information: SO, and patient chart

II. NURSING CLINICAL ABSTRACT

Ms. Mejica, a 8 years old client from Brgy. Tangbo, Arteche, Eastern
Samar was admitted to Eastern Samar Provincial Hospital with a chief complaint
of fever. According to the SO, four (4) days prior to admission she was noted
having cough, fever and abdominal cramps. Three (3) days prior to admission,
the patient was brought to Arteche District Hospital and was subsequently
admitted as a care of Acute Bronchitis. The parents of the patient decided to
bring their child at Eastern Samar Provincial Hospital (ESPH) for they believed
their daughter is not getting okay. Dr. admitted her with an admitting diagnosis of
Urinary Tract Infection (UTI). As of now, the patient feels okay, afebrile, no
cough anymore and abdominal cramps. Ms. Mejica is about to discharge anytime
today.
III. NURSING HISTORY

1) History of Present Illness

According to the SO, Ms. Mejica was noted having

cough, fever, and abdominal cramps four days prior to
admission. Three days prior to admission, the patient was
brought to Arteche District Hospital and was subsequently
admitted as a care of Acute Bronchitis.

2) Past Health History

According to the SO, this is the third time around the

patient has been hospitalized, she had been recently diagnosed
with Dengue Fever.

3) Immunization

According to the SO, Ms. Mejica had completed

vaccination during her childhood years.

4) Family Health History

 Father Side

According to the SO, common illnesses that is in his

paternal side are having hypertension and arthritis. Her Lolo
died because of a particular disease and had been diagnosed
having with hypertension.

 Mother Side

According to the SO, her Lolo have arthritis and her

mother have an asthma.

5) Allergies

The patient has no allergies in any food or drugs.

IV. Gordon’s Typology of 11 Functional Health Patterns

1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

Before hospitalization, the patient was having a good time playing with
her siblings. She always had a full energy in any school activities. According
to her mother, patient M rarely gets sick. If she rates her child’s health, it is
about 9 on a health scale, 10 as the highest and 1 as the lowest. If her child
gets sick, she has her daughter consult a doctor immediately. She lets her
child drink a lot of water every day and take enough rest. There are times, she
send her child to albolaryos for they believed there are illnesses that only
albolaryos could heal.

During hospitalization, the mother of the patient says her child cannot
play anymore with her siblings because of the pain she have. She often plays
mobile games on her own and watches random videos. The patient was not
as energetic as she was before she has been hospitalized.

2. NUTRITION-METABOLIC PATTERN
Before hospitalization, the patient weighs 29 kilograms. She eats three
times a day. According to her mother, she eats foods that are being
prepared; she is not choosy in terms of eating. She eats a lot of fruits and
vegetables. She takes juices twice a day, included to these is water. In a day,
she takes approximately 2 liters of water.

During hospitalization, the SO said that her daughter doesn’t have the
appetite to eat heavy meals. She just wants to eat sweet biscuits and juices.

Edible
Food Items Approximate Portion Calories Total
Measurement (weight in Calories
grams)
Bread (Pan de 2 pieces (5x5cm 40 100 200
Sal ) each)
Rice, cooked ½ cup 80 100 300

Squash ½ cup cooked 45 16 35

Scrambled egg 2 serving 365.2 730.40

String beans ½ cup cooked 45 15 35

pod

Canned goods 2 pieces 30 30 60

Banana cue 1 ½ 0f 9 1/2 x 1 20 40 85

Total calories 1 445.4

 Total calories needed (Age: 8 years old, and 29 kg) 1,570

Difference 124.6

3. ELIMINATION PATTERN
Before hospitalization, Ms. Mejica urinates 4 times a day which
measures approximately half of a cup in every urination. Urine was yellow
amber in color. Every time there is a need for urination, she finishes first what
she is doing before urinating. Few days before she has been hospitalized, the
patient feels a slight painful during urination, pain was about in the 6 th level of
the pain scale, 10 as the highest and 1 as the lowest. She defecates only
once a day with brown stool. She feels no discomfort during defecation.

Output (ml) Total

Shift Intake (ml) Urine (Output)

Breakfast 1 glass of milk 230 ml 240 ml

1 glass of water 180 ml 350 ml
Morning 2 glasses of water 500 ml 450ml
Snack
Lunch 2 glasses of juice 500 ml 220 ml
1 glass of water 250 ml 200 ml
Afternoon 1 glass of juice 250 ml 250 ml
snack

Dinner 1 glass of juice 240 ml 220 ml

Total Intake 2,150 ml 1,930 ml

According to the input and output record of Ms. Mejica, she has an
imbalance input and output. And she stated that she has difficulty in urinating.

During hospitalization, she urinates frequently from 9-11 times with a

measurement of ½ of a cup a day with a yellowish color, she feels slight pain
during urination, and the level of the pain in pain scale is the same on before
hospitalization.

4. ACTIVITY-EXERCISE PATTERN
Before hospitalization, the patient considers her walking going to
school as a form of exercise since their school is just a walking distance.
Taking rest particularly lying on bed and playing is her way to overcome his
tiredness and stress.
Functional Level Classification Findings / Assessment

1. Perceived ability for bed mobility 0

2. Perceived ability for general mobility 2

3. Perceived ability for dressing 2

4. Perceived ability for bathing 2

5. Perceived ability for grooming 0

6. Perceived ability for toileting 3

7. Perceived ability for home maintenance 1

8. Perceived ability for shopping 4

9. Perceived ability for cooking 4

10. Perceived ability for feeding 2

11. Perceived ability for use of telephone 0

12. Perceived ability for going to places out 2

of walking distance

Legends:

0 = complete independent
1 = requires use of equipment or device
2 = requires help from another person for assistance, supervision, or
teaching
3 = requires help from another person and equipment or device
4 = complete dependence

Because of her condition, patient M’s ability to do such activities is so

much affected. She thinks, she cannot be able to play anymore with her
siblings and cannot go to school. She needs assistance in performing hygiene
practices such as dressing, bathing, etc. She also needs some support and
assistance in going to the CR.
5. SEXUALITY-REPRODUCTIVE PATTERN
The patient is still young and single, thus, she is not yet engaged in any
sexual activities.

6. SLEEP-REST PATTERN
Before hospitalization, Ms. Mejica sleeps at night around 7pm and
wakes up at around 6:30am. She naps usually around 12noon up to 1:30pm
after morning class. According to her mother, she doesn’t have any difficulty
falling asleep and wakes up the same time every day.
During hospitalization, she can’t easily fall asleep in the hospital
because she is used to sleep in their house and not on other houses or even
hospitals as stated by the patient’s mother.

7. COGNITIVE-PERCEPTUAL PATTERN
All of her senses are all functioning. She is aware of her environment.
She has the ability to understand, communicate, write, remember and make
decisions.

8. ROLE RELATIONSHIP PATTERN

Before hospitalization, the patient has a good relationship in her family
and her friends. She has lot of friends at school because she is friendly.

During hospitalization, the relationship of the patient to her friends and

siblings was lessened and decreased due to a great situation which trapped
her to continue it.

9. SELF-PERCEPTION – SELF-CONCEPT PATTERN

Even if the patient feels pain, she doesn’t mind and tells her parents,
“okay

laak”.

10. COPING STRESS TOLERANCE PATTERN

When the patient feels stressed and tired, as a management, she

sleeps, eat and play mobile games with her siblings.

11. VALUE-BELIEF PATTERN

The patient believes that Jesus is our savior, friend and brother. She
also believes that she will be soon okay with the power of Jesus.
 V. PHYSICAL ASSESSMENT (Head-to-Toe Assessment)

General appearance:
Ms. Mejica is awake and coherent; she has a good posture and gait. She
appears calm and properly groomed. She is oriented to time, place and person.

AREA TECHNIQUES USED NORMAL ACTUAL ANALYSIS

ASSESSED FINDINGS FINDINGS

SKIN:

Color inspection light to deep Light to deep Normal

brown brown

Texture palpation smooth, Smooth, normal

presence of hair presence of hair

Skin turgor palpation skin springs Skin springs Abnormal

back back slowly due to
immediately when pinched- some
when pinched about 4 seconds dehydratio
n

Temperature palpation uniform within Uniform within Normal

normal range normal range

presence of palpation no edema no edema Normal

edema

presence of palpation some birth no lesion, with Normal

skin lesion marks, some flat flat mole
and raised moles

HAIR:

Color inspection brown or black Black Normal

distribution inspection evenly evenly Normal

distributed distributed

hair thickness inspection either very little Great number of Normal

and thinness or great deal of body and scalp
body and scalp hair
hair

thick or thin hair

texture and palpation smooth and silky Rough and dry Due to
oiliness poor
hygienic
 measures
and some
dehydratio
n

presence of lice inspection without lice without lice Normal

NAIL:

Color Inspection Pinkish Pinkish Normal

Shape and Inspection and Smooth, convex Smooth, convex Normal

texture palpation in curvature, in curvature,
long long

Thickness Inspection Extremely thin Extremely thin Normal

Capillary refill Performed blanched Prompt return of Returns Normal

test pink or usual immediately
color

HEAD:

Size, shape Inspection Rounded Rounded Normal

and symmetry (normocephalic) (normocephalic)
symmetric, with symmetric with
frontal, parietal frontal, parietal
and occipital and occipital
prominences prominences

Head Inspection and 35-45 cm 38 cm Normal

circumference palpation

Presence of Inspection Smooth, uniform Smooth, uniform Normal

mass or in consistency, in consistency,
nodules absence of absence of
nodules and nodules and
mass. mass.

Head inspection Can lift head Can lift head Normal

movement slightly and turn slightly and turn
them from side them from side
to side to side

EYES:

Eyebrows: hair Inspection Hair evenly Hair evenly Normal

distribution and distributed, skin distributed, skin
alignment intact, eyebrows intact, eyebrows
 symmetrically symmetrically
aligned aligned

Eyelashes: inspection Equally Equally Normal

evenness of distributed, distributed,
distribution and curled slightly curled slightly
direction of curl outward. outward.

Conjuctiva and Inspection Bulbar Bulbar Normal

sclera Conjunctiva is conjunctiva is
clear with tiny clear with tiny
capillaries capillaries
visible, Palpebral visible,
conjunctiva is Palpebral
pink, no conjunctiva is
discharge, sclera pink, no
is white discharge,
sclera is white

Response to Inspection Illuminated Illuminated normal

light pupils constrict pupils constrict

Ability to read inspection Able to read Cannot able to Abnormal

newsprint news print read newsprint due to
materials aging

NOSE:

Symmetry, Inspection Symmetrical, Symmetrical normal

shape and straight and and uniform in
color uniform in color color

Occurrence of Inspection Pink mucosa, no Pink mucosa, normal

redness, discharge and no discharge
swelling and swelling free of and swelling
discharge lesion free of lesion

Facial sinus Palpation No tenderness No tenderness Normal

MOUTH:
Lips:
Symmetry, Inspection and Symmetry of Symmetry of Normal
color, palpation contour uniform contour uniform
tenderness pink color, soft, pink color, soft,
moist, smooth moist, smooth
texture texture

Gums:
Color and Inspection Pink, moist and Pink, and moist normal
moisture firm

Teeth:

Number Inspection Complete teeth- Incomplete- 17 Abnormal

32 number of number of teeth due to
teeth aging

Position and Inspection Central position, Central position, Normal

color pink in color, pink in color,
slightly round slightly round

Smell Inspection No foul odor Mild foul odor Abnormal

due to poor
hygienic
measures

EARS:

Auricles: Inspection Color is same as Color is same Normal

Color, the color of the as the color of
symmetry of face, the face,
size and
symmetrical symmetrical
position
auricles align in auricles align in
the outer the outer
canthus of the canthus of the
eyes eyes

Texture, Palpation Mobile, firm, no Mobile, firm, no Normal

elasticity and tenderness, tenderness,
areas of pinna recoils pinna recoils
tenderness after it is folded after it is folded

NECK:

Appearance inspection Short and mobile Short and Normal

and movement mobile
THORAX:

Color Inspection Light to deep Brown Normal

brown

Chest shape Inspection Rounded Rounded Normal

Respiratory Inspection 16-20cpm 15cpm Normal

pattern

Breath sound Auscultation Vesicular, Clear breath Normal

broncho- sounds
vesicular and
bronchial

HEART:

Cardiac rate auscultation 75-120 bpm 114 bpm Normal

and rhythm

Apical pulse auscultation Left 5th ICS, Left 5th ICS, Normal
lateral to lateral to
midclavicular line midclavicular
line

ABDOMEN:

Contour Inspection Rounded Rounded Normal

Bowel sound auscultation High pitched High pitched Normal

irregular gurgles, irregular
hyperactive gurgles,
hyperactive

UPPER &
LOWER
EXTREMITIES
:

size inspection Equal in size Equal in size Normal

Strength and inspection Can flex and Can flex and Normal
tone extend arms and extend arms
 legs and legs

Mobility Inspection mobile Mobile Normal

VI. VITAL SIGNS

Area Technique Actual Normal Analysis

Assessed Used Findings Findings

Temperature Measured 37.7 degree 36.5-37.7 Normal

using a Celsius degree

thermometer Celsius
Pulse rate Palpation 114 bpm 75-120 bpm Normal
Respiratory Inspection 30 bpm 15-20 bpm Normal
rate