Patient Assessment Data Base: A. General Data: 1. Patient s Name: C.S 2. Address: Pangasinan 3. Age: 1 4. Sex: M 5.

Birth Date: April 20, 2009 6. Rank in the family: 1st 7. Nationality: Filipino 8. Civil Status: Single 9. Date of Admission: February 19, 2011 10. Order of Admission: 11. Attending Physician: B. Chief Complaint: LBM C. History of Present Illness: Diarhea and Vomiting

D. Past Health History/Status: 1. Childhood Illnesses: The patient stated that he had Fever, cough, colds and Stage 1 Dengue 2. Immunization: The patient completed his immunization 3. Major Illnesses: None 4. Current Medication: The patient takes paracetamol 5. Allergies: The patient stated that he has no allergy E. Family Assessment: NAME J.S G.S C.S RELATION Husband Wife Son AGE 26 25 1 SEX Male Female Male OCCUPATION OFW Housewife None EDUCATIONAL ATTAINMENT Under Graduate College Under Graduate College None

F. System Review: 1. Health Perception Health Management Pattern y Subjective: Client s perception of health: For the patient health is very important to every human being. Client s perception of illness: The patient stated that illness affects his health Health maintenance and habits: To maintain health and wellness in the family the patient emphasized the

importance of cleanliness, exercise, eating healthy and nutritious foods such as vegetables and by following the doctors advice.

Compliance with prescribed medication and treatment: He complies in taking her medication and treatment
prescribed by the physician.

2. Nutritional Metabolic Pattern y y y y 3. Elimination Pattern Bowel habits: The patient defecates three times a day. y Color: Brown y Odor: Aromatic y Consistency: Watery y Laxative use: None Bladder: The patient has no difficulty in urinating. y y Color: Yellowish Odor: Aromatic Appetite: The patient has good appetite Food: The patient eats vegetables such as ginataang kalabasa Water: The patient drinks 3-5 glasses a day. Beverages: The patient drinks any beverages such as juice, milk, and chocolate drinks.

Alteration: None

4. Activity Exercise Pattern y Subjective: Self care ability __Feeding __Bathing __Bed mobility

__Dressing __Toileting __Home maintenance

__Grooming __Cooking __Others

5. Cognitive Perceptual Pattern y Subjective:  Hearing: Responds quickly every time we asked questions. He is not using any hearing aids.  Vision: The patient does not use eye glasses  Sensory perception: Upon tapping his shoulder he responded quickly. The patient can differentiate
between sweet and bitter and can also smell the fragrance of cologne.  Learning styles: In order to gain information and enhance knowledge, his mother teach him on whats going on.

6. Sleep - Rest Pattern y Subjective: Sleep Habits: The patient sleeps in afternoon and at night. Special sleeping problems: Hours of sleep: The patient sleeps 8-9 hours a day Sleeping alterations: Sleeping aids: The patient use sleeping aids such as watching T.V and playing in his bed

7. Self Perception and Self Concept Pattern y Subjective: Feeling about current state Description of self Known capabilities and weaknesses Self worth

8. Role Relationship Pattern y Subjective: Perception of major roles and responsibilities in the family Perception of major roles and responsibilities at work Perception of major social roles and responsibilities

9. Sexuality Reproductive pattern 10. Coping Stress Tolerance Pattern y Subjective: Perceptions of stress and problems in life: Coping methods and support systems used:

11. Value Belief Pattern y Subjective: Values, goals and philosophical beliefs: Religious and spiritual beliefs:

G. Heredo Familial Illness Maternal: Diabeties, UTI, Hypertension Paternal: Hypertension H. Developmental History I. Physical Assessment A. General Survey 1. Overall appearance and grooming 2. Actual height and weight vs. Ideal body weight 3. Symptoms of distress 4. Posture gait 5. Affect, mood 6. Relevance and Organization of thought B. Vital Signs C. Regional Exam 1. Hair, head and face Inspection: Palpation:

Percussion: Auscultation: 2. Eyes: 3. Nose: 4. Ears: 5. Mouth and Throat: 6. Neck and Lymph nodes: 7. Skin: 8. Nails: 9. Thorax and Lungs: 10. Cardiovascular: 11. Breast and Axilla: 12. Abdomen: Inspection: Palpation: Percussion: Auscultation: 13. Extremities:

14. Genitals: 15. Rectum and Anus: 16. Neurological/ Cranial nerves

II. Personal / Social History A. Habits/ Vices a. Caffeine: b. Smoking: c. Alcohol: d. Tea: e. Drugs: f. Lifestyle: g. Social Affiliation: h. Rank in the family: i. Travel: k. Educational Attainment:

III. Environmental History

IV. Pediatric History

V. Introduction

VI. Anatomy and Physiology