ASSESSMENT

A.BIOGRAPHICAL DATA Name: Patient K Age: 1 year and 11 months old Gender: Female Address: Purok Durian, Pangi, Maco, ComVal Province Birth date: March 18, 2011 Birthplace: Tagum City Ethnicity: Cebuana Religion: Roman Catholic Marital Status:Single Father: Antionio Budiongan Occupation: Marsman Employee Mother: Jenelyn Budiongan Occupation:Housewife Date of Admission:February 27,2013 Attending Physician: Dr. Gloria Thelma Lagmay Initial Diagnosis: LRTI Final Diagnosis: CAP- C Source of Interview: Client's grandmother Chief Complaint PTA, Patient complaining of fever. History of Present Illness Patient experienced productive cough for the couple of days and complaints of fever during the day of admission. Past Medical History Patient K was 1st hospitalized when she was 5 months old. During that time, she was diagnosed with UTI. She never experienced any childhood illnesses such as measles and chickenpox. This was her 2nd hospitalization. She also completed her childhood immunization. Her parents let her take OTC drugs for fever and some other conditions that are not severe. She never experienced any injuries or accidents as her grandmother stated. Personal History Patient's K resides with her mother at her grandparents house at Purok Durian, Pangi, Maco, ComVal Province. She has an older brother who lives with their father. Their parents were separated. Patient K is only one year and 11 months old. Her grandmother stated that she loves to play outside the house together with the other kids.

Nutritional History According to Lola Rogelia, the grandmother of Patient K, they usually serve lugaw and any kind of soup to her. Patient K loves to eat papaya fruit. She is also on bottle feed, drinks 4-5 glasses of water every day and sometimes she drinks juices and soda. During her hospitalization her grandmother allows her to drink gatorade. Family History Both parents of Patient K are still alive but separated. Her mother is 29 years of age without complaints with regards to her health. Her father is 39 years old, alive and well. She is the youngest in the family with an older brother. Socio-Economic History Patient Ks father is an employee of Marsman, a Banana Exporting Company. His salary is twelve thousand a month. Her mother is a housewife. During her hospitalization she availed her father's health insurance in the company. As monthly allowance of Patient Ks, her father gives half of his salary to Lola Rogelia who serves as Patient Ks guardian.

COURSE IN THE WARD DOCTOR'S ORDER Date/ Shift 2/27/13 5:50 am Progress Notes Doctor's Order > Please admit >DAT >VS Q4 >IVF D53NACI 500cc @ 60cc/hr >IVF TF D5IMB 500cc @ 60cc/hr >labs: CBC S/E V/A CxR >Meds: 1.)Paracetamol 250/5; 3ml q4 for fever 2.)Paracetamol 125g; syrup or rectum for fever *38.5 degree celcius 3.)Salbutamol + GF syrup; 3ml TID 4.)Cefuroxime, 330mg IVVT q8 ANST *will info. AP *refer acc. >regulate present IVF @ 50cc/hr >IVF D5IMB 500cc @ SR >Cont. Meds > Cetirizime for fever >IVF D5IMB @ SR x 3 cycles >Cont. Meds >Restime gtts 1ml TID >MV (Nutrilin) Syrup 1tsp OD > paracetamol q4 IVTT x 4 doses then PRN there after >IVF D5IMB 500cc @ SR >DC IV Cefuroxime >Ceftriaxone 500mg q 12 via soluset ANST- 10 >for thypi dot now > IVF D5IMB 500cc @ SR >Rpt. Hgb count and HCT count @ 6am tom. > Cont. Meds >IVF D5IMB 500cc @ SR

2/28/13

3/01/13 9am

3/01/13

3/02/13 8:30am

>IVF 3NACI @ 65cc/hr x 80 then regulate @ 50cc/hr >Run 100 cc present IVF now >IVF D5IMB 500cc @ SR 3/03/13 8:30am >Reapt CBC now >IVF D5IMB 500cc @ SR D/C Restime gtts >Cont. other Meds >ampi Salbutamol 350mg IVTT ANST >IVF TF D5IMB 500c @ SR >Reapt. Platelet count & HCT count now.Then refer result aware going home >Pls give exact dose >Ampicillin +Sulmefan @ 2pm today Then D/C present IVF + IV Meds Then MGH request 1.) Paracetamol 1tsp q4 PRN for fever 2.) Salbu + GF 3ml TID until with occasional cough 3.) Cefirixime gtts 15ml BID x 6 days >Proper hygiene >Check up @ my clinic in Friday >Hold discharge >Cont. Meds >Cont. IVF & IV Meds >IVF TF D5LR 1L @SR >Hold Nutrilin Syrup >Rept. Platelet net. @ 6pm tonight

11:35am

3/04/13 9am

10am

>Rept. Platelet,hematocrit @ 6am 9:15pm 3/05/13 >Cont. Meds >IVF D5LR @ 1L SR >Rept. Platelet count & HCT count @ 6am tom >IVF D5IMB 500cc @ SR >Pls give last dose of Salbutamol @ 2pm today. Then D/C prescription >(-) fever ;MGH >Proper hygeine

4pm 3/06/13 9:10am

>Check up @ Poly Clinic in Monday Vital Signs Monitoring

Date/ Shift
02/27/13 311 117 02/28/13 711 311

Time
8pm 12mn 4am 8am 12nn 4pm 7pm 8pm 12mn 117 4am 8am 12nn 311 117 4pm 8pm 12mn 4am 9am 12nn 3-11 11-7 4pm 8pm 12mn 4am 8am 12nn 3-11 4pm 6pm 8pm

Temp (C)
37.4 38.3 37.8 36.5 39.3 36.1 38.4 36.4 36.2 39.1 39.1 37 38.3 36.5 36.4 36.7 38 37 38.3 36.5 36.6 36.5 36 36 36.6 37.8 37.1 36.8 36.1 39.1 37.2

PR (bpm)
112 110 112 116 114 108 110 110 110 120 120 121 120 118 127 116 120 121 120 122 125 128 125 124 120 120 110 111 122

RR (cpm)
24 23 23 26 26 25 25 25 24 20 26 27 26 24 24 28 26 27 26 27 23 26 24 28 26 28 26 25 26

03/01/13

73

03/02/13

7-3

03/03/11

7-3

03/04/13

11-7

12mn 4am 6:45am

73

8am

12nn 311 03/05/13 117 73 37 03/06/13 113 4pm 5pm 12mn 4am 8am 12nn 4pm 8pm 12mn 4am

36.9 37.1 37.2 37.3 37 36.2 35.9 36.3 36.4 36.6 36.8

118 112 116 115 114 124 126 124 126 118 116

26 28 27 28 27 26 25 26 28 29 28

IVF MONITORING Date/Shift 02/27/13 311 02/28/13 117 311 03/01/13 117 73 03/02/13 117 311 03/03/13 117 73 03/04/13 117 311 03/05/13 73 12 D5LR 1L 50cc/hr 2:30pm 10 11 D5IMB D5LR 500cc 1L 50cc/hr 50cc/hr 1am 5pm 5pm 2:30am 8 9 D5IMB D5IMB 500cc 500cc 50cc/hr 50cc/hr 2am 11:30am 11:30am 1am 6 7 D5IMB D53NACI 500cc 500cc 50cc/hr 65cc/hr 4am 4pm 4pm 2am 4 5 D5IMB D5IMB 500cc 500cc 50cc/hr 50cc/hr 6am 3pm 3pm 4am 2 3 D5IMB D5IMB 500cc 500cc 60cc/hr 50cc/hr 4am 8pm 8pm 6am 1 D53NACI 500cc 60cc/hr 6:25pm 4am Bottle # Kind of Solution Volume Gtts cc/hr Time Started Time Consumed

SYNTHESIS OF CLIENT'S CONDITIONS CONCLUSION With regards to the information being drawn together, our patient was diagnosed of Pediatric Community Acquired Pneumonia-C. Pediatric Community Acquired Pneumonia-C was given emphasis during the course of case study. With these, monitoring the clients condition is needed in terms of signs and symptoms of this condition as well as the degree and severity of its manifestation so as to collaboratively intervene to stabilize the patient. Additionally, taken the consideration of carrying out the prescriptive orders of medicine are also given importance. However, the progress and fast recovery of the patient depends on the cause and severity of the condition, therefore modifications in activities, exercise, and more fluid intake and may use the DAT diet (Diet as tolerated).