I.

Biographic Data

PATIENTS NAME: R.S ADDRESS: Bgy. 142 CML Compound Project 6, Quezon City AGE: 4 months old GENDER: Female RELIGIOUS AFFILIATION: Mormons ROOM & BED #: 5069-B2 CHIEF COMPLAINT: PROVISIONAL DIAGNOSIS: ATTENDING PHYSICIAN: Dr. Norma V. Zamora

II.

Nursing History A. Past Health History

As verbalized by the mother the only illness that the patient had was the hydrocephalus. The mother said Nung ipinanganak ko siya sabi sakin itim ang kulay niya, nasobrahan kasi ng araw yung baby ko sa tiyan ko dahil ayokong magpa caesarean. Hindi rin siya umiiyak nung ipinanganak ko ang baby ko. According to patients mother the patient is still completing her immunization because some immunizations are to be given on a specified time but his mother said that they will complete her immunization. The patient doesnt have allergies said by the mother. The mother verbalized that the patient had no accidents but it is her third time to be hospitalized. The patients first hospitalization was on June 2, 2013 when shes only 1 month old. Her second hospitalization was on June 11, 2013. And her third hospitalization was on September 18, 2013 up to now. Currently the client is taking medications for her present illness such as PedZinc as his vitamins as verbalized by his mother. According to his mother they didnt have a foreign travel yet.

B. History of Present Illness Patient was admitted due to hydrocephalus for three days with diagnosis of acute gastroenteritis by Dr. Hembrador. Aside from the diagnosis, no other disease or complication was seen or diagnosed.

C. Family History According to patients mother she said that they have no hereditary diseases on their side. And on father side they dont have any hereditary diseases also. The patients mother also added kaya lang naman nagka ganyan ang baby ko kasi habang 7 months akong buntis nagkaroon ako ng tigdas at bulutong kaya hindi ako nakakapunta sa ospital para makapag pre-natal check up kasi baka makahawa lang ako pag nagpunta ako sa ospital.

Genogram Emalyn Silia Mother (Alive & well) 35 years old Ronald Silla Father (alive & well) 45years old

Justine Silla (Alive & well) 13years old

Jackielyn Silla (alive & well) 9 years old

Mary Rose Silla (Alive & well) 9 years old

Patient RS Client

LEGEND:

Female

Male

Client

III.

Patterns of Functioning A. PSYCHOLOGICAL HEALTH 1. COPING PATTERNS

During this age the baby must be crying at all times, but our patient is not. Shes always lying in the bed because her mother cannot carry her because of her condition. Being confined in the hospital can be considered as a stressor to her. Her mother said, simula nung ipinanganak ko siya hindi pa siya umiiyak, hindi ko alam kung bakit Furthermore, she tends to cope with it by having rest and sleep. Interpretation: Analysis: Coping may be described as dealing with change; successfully or unsuccessfully. Coping is the cognitive and behavioural effort to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person. SOURCE: (Fundamentals of Nursing by Kozier & Erbs, Eight edition volume two, p.1068) 2. Interaction Patterns Regarding the patients condition she seems to be quiet and not active while were doing the assessment. As we does our assessment, even if her mother talks to her or play with her she doesnt have any reaction, maybe because of her illness. The patients doesnt laugh, play, or have any reaction especially when getting her vital signs. Interpretation: Analysis: Crying is the first means of communication, and parents can usually differentiate cries. SOURCE: (Health Assessment in Nursing by Jannet Weber & Jane Kelley, 3 rd Edition, p. 694)

3. Cognitive Patterns Patient RS doesnt have any response to us. She doesnt do any facial expression, laugh or cry. Shes just lying on her bed, what she does in the hospital is just sleeping. Interpretation: Analysis: The sensorimotor stage, from birth to around 18 months, involves the development of the intellect and knowledge of the environment gained through the senses. During this stage, development progresses from reflexive activity to purpose full acts. SOURCE: (Health Assessment in Nursing by Jannet Weber & Jane Kelley, 3 rd Edition, p. 694) 4. Self-concept Pattern According to her mother simula nung na ospital ang baby ko ganyan na siya di umiiyak o tumatawa basta nakahiga lang siya at kain, tuloglang siya. Interpretation: Analysis: Self-concept is ones mental image of oneself. A positive self -concept is essential to a persons mental and physical health. An individual possessing a strong self-concept should be better able to accept or adapt to changes that may occur over the life span. SOURCE: (Fundamentals of Nursing by Kozier & Erbs, Eight edition volume two, p.1003)

5. Emotional Patterns She is not cheerful and playful. She doesnt cry when not comfortable or when she is not feeling well and she doesnt have any reaction even cries when she doesnt want the food, hungry, irritated and sleepy, and get frustrated when her needs are not met in time. She doesnt responds when you call his name. Interpretation: His emotional pattern and actions are not appropriate with his age therefore theres deviation from normal

Analysis: Emotional pattern develops expressing different feelings and begin to fear being left by their parents. They get angry and frustrated when their needs are not met in a reasonable amount of time. SOURCE: (Fundamentals of Nursing by Kozier & Erbs, Eight edition volume two, p.1003) . B. SOCIO-CULTURAL PATTERNS 1. Cultural Patterns At present they are now presently staying Bgy. 142 CML Compound Project 6, Quezon City. According to his mother, they have their traditions like they are not drinking soft drinks that are dark color for example coke, pepsi and sarsi.

Interpretation:. Analysis: Being adaptive to cultures of others and thus maintaining your own culture signifies how well a person adapts to its environment without completely changing his/her original culture. SOURCE: (Fundamentals of Nursing by Barbara Kozier 7th edition pg 178)

2. Recreation Patterns The only bonding time with the patients parents is when they are in the hospital. Interpretation: The clients recreational pattern is normal since they find quality time within his family to bond. Analysis: Recreational activity and bonding, hobbies and other interests, and vacations would promote an individuals level of wellness. SOURCE: (Fundamentals of Nursing by Barbara Kozier 6th edition pg 263