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XAVIER UNIVERSITY

ATENEO DE
CAGAYAN

Current Educational Level: Kinder 2

LDRR and Pallor. Intermittent flues


and was given paracetamol. 3

Informant: Melanie Caare

weeks prior to admission; fever and

Relation: Mother

cough. Consulted with Admitting

Admission Date: November 30,

Physician,

PEDIATRIC ASSESSMENT TOOL

2015

antibiotic. Diagnosed leukemia on

I. GENERAL INFORMATION

Time: 11:45 am

Name: Myrone Caare

Chief Complaint:Fast breathing and

discharged improved. Patient was

Pallor

advised for follow-up today with

COLLEGE OF NURSING
NCM 102 RLE

Age: 5 years old


Birthday: Aug. 22, 2010
Civil Status: Single
Sex: Male
Religion: Roman Catholic

given

days at CUMC due to infection and

CBC. After the CBC patient is

Attending Physician: Dr. Go

advised for admission.


Diagnosis/Impression: T/C
Upon Assessment:

Lymphoprolferative Disorder

Vital Signs: HR 131

II. History of Present Illness


3 months prior to admission: mother
noticed

Occupation: Student

fatigabilitis. No medication and no

CIty

Cordinez,

November 15, 2015. Admitted for 8

Income: None

Address: TablonCagayan de Oro

Dr.

that

consultation.1

the

patient

month

prior

has
to

RR 37 BP 100/60

Temp 37.5oC

O2 Sat 98 HT 104

WT 15.4kg

BMI 14.24
Interpretation of BMI: Normal

admission; parents noticed slight


1

II.

PAST

CHILD

ILLNESS

MEDICAL / SURGICAL HISTORY


Illness
Dengue
Amebiasis
Pneumonia
Infection

Date
2014
2015
2015
2015

III. FAMILIAL RISK FACTORS


Hypertension: Both
Tuberculosis: Paternal
CVA/Stroke: None
Diabetes/Mellitus: Both
Kidney Disease: None

Current Medications
Drug

ency/Route
Diphenyhy 12.5mg/5m
dramine

Indication

TID
8AM
1PM

Paraceta

6PM
250mg/5ml

Symptom

associated

mol

, 4ml, Q4,

atic relief

with

(Biogesic)

PO, PRN

of pain

Relief of
symptoms

ide

blood

perennial

November

for T > or

and

(Benadryl)

transfusion

and

30, 2015

equal to

fever,

37.8C

prophyla

November

seasonal

30, 2015

allergic

xis for

rhinitis

Clindamyc
(Cleocin

75mg/5,
5ml, PO,
QID
8AM

infections

Pedia)

12NN

Pneumon

November

4PM

ia

in

Heart Disease:None
Cancer: Paternal

Nystatin
(Mycostati
n)

Mental Illness: None

l, 5ml, PO,

hydrochlor 30 min pre-

30, 2015

Epilepsy: None

Dose/frequ

30, 2015

November

children
Severe

8PM
Syrup
(suspensio
n) 1ml,
Swish and
Swallow,

Piperacillin

900 mg IV

Treatment

Drip, Q6,

of severe

Tazobacta

ANST (-)

G-

m (Vigocid)

12 MN 6

infection

November
30, 2015

Orophary
ngeal

Racecado

candidias

tril

is

AM 12
NN 6 PM
10 mg
sachet 1
sachet per
10 ml H20,
PO, TID

and other
susceptibl
e bacteria

Supplem
ent to
oral

(Hidrasec)

8AM

rehydrati

December

1PM

on

1, 2015

6PM

General Appearance and Mental

Use of Accessory Muscles:

Status: Properly groomed and

Trapezius and sternocleidomastoid

presentable yet pallor is present in


boys hands and exhaustion of the

Nasal Flaring: Present during


inhalation

Zinc-

5 ml, PO,

Used for

eyes. Also, the patiently is visibly in

Sulfate

OD, 6PM

treatment

a weakened state during

Abnormal Breath Sounds:

interaction.

Wheezing on both side of the lungs

Personal Hygiene: Well kept and

Cyanosis: None

clean but dried saliva surrounds lips

Clubbing of Fingers: None

syrup

and

(E-zinc)

preventio

December

n of zinc-

1, 2015

deficienc

Benzydam

TID, 8 AM

y
Relief of

Hair: kept and tidy

Sputum Characteristics: None

ine

1 PM 6

inflamma

Clothing and Manner of Dress:

Dyspnea related to: Hepatomegaly

(Difflam

PM

tion in

properly dressed and wears

and spleenomegaly

Spray)

oral

December

mucosa

9, 2015

comfortable clothes
i.Respiration
Objective

VI. ASSESSMENT OF SYSTEMS

Respiratory Rate: 131 Depth: Deep

Objective

Symmetry: Unequal

Cough/Sputum: Productive Cough


History of:
Bronchitis __Asthma__
Tuberculosis ____
Use of respiratory aids None

Recurrent Pneumonia /

Rhythm: Tachycardia

ii. Circulation

Pulse

Subjective

Carotid: 130

Ankle/Leg Edema: None

Radial: 129

Extremities:

Popliteal: 130

Numbness: None Tingling: None

Temporal: 129

Objective

Femoral: 130

BP

Dorsalis Pedis: 130

Lesions None Nail Color: pale pink

R: Lying: 100/60

Capillary refill: more than 2 seconds

Condition Oral Mucosa: Lesions

Color: pale pink

present on tongue

Cyanosis/Pallor: Palmar pallor

Teeth: Clean

present

Daily food intake

Varicosities: none

Breakfast: Soup, rice

Nail beds: less than 160; no

Lunch: Chicken, vegetable, rice

Sitting: 100/60
L: Lying: 100/60
Sitting: 100/60

Heart Sounds:
Rate: 131

clubbing

Mucous Membranes: swelling on


buccal region both sides

iii. Nutritional/ Metabolic Pattern


Skin Color: Brown
Lesions: White lesions found in
tongue and crusted lips
Hair: Color Black Texture Smooth

Dinner: Soup, rice

Snacks: Milk, biscuits, chocolate


sticks
Food Supplements/Vitamins:
Celine
Food Allergies: None

Color: Dark brown

Hearing: Good

v. Activity-Exercise

Smell: Good

Daily Activities: Goes to school

Aids for vision: None

everyday, takes a bath alone, study


Leisure time activities: Playing with

iv. Elimination

friends, watching TV, coloring

Bowel habits:

Exercise routine: Running with

Frequency: twice a day


Consistency: watery stools with
particles
Color: dark brown
Amount: at least one cup (240 ml)
Constipation: none
Bladder habits:
Frequency: twice a day
Amount: less than 100cc

Aids for hearing: None


viiii. Mental Status
Oriented:_/_

friends

Disoriented:___

vi. Sleep-Rest

Time:_/_

Time of sleep: Four to five hours in

Place:_/_

the afternoon, eight hours during

Person:_/_

the night
Sleep aids: None
Quality: Good
vii. Sensory-Perceptual
Vision: Good

Alert:_/_
Combative:___
Drowsy:_/__
Stuporous:__
Comatose:___
5

Lethargic:___
Pupil Size/Reaction:

Severity: Severe
Time( Onset, Frequency, Duration):

Safety
Allergies/Sensitivity: None

Right: Normal

Whenever affected site is touched

Reaction: None

Left: Normal

Objective Data (S/sx): Infiltrated IV

Blood Transfusion/number:

Posturing: Normal

infusion site

When: November 30, 2015

Speech Impairment: slight difficulty

History of Accidental Injuries: Head

in talking due to lesions on mucosa

injury

Ability to express: cooperative when

Fractures/Dislocations: None

asked about feelings and pain

Arthritis/Unstable joints: None

VII. Pain/Comfort

VIII. Role-Relationship Pattern

Subjective Data

Ordinal position of client in the

Precipitating:
Quality of pain: 9 (pain scale)
Radiating at: infusion site @ (R)

family: 3

rd

Back Problems: None


Changes in moles: None
Enlarged nodes: None

Primary caregiver of client: Mother

Unusual Bleeding: None

Other support system of client:

Prosthesis: None

Father, Aunt, Grandmother


hand

X. DEVELOPMENTAL
MILESTONES
(Indicate clients age)
Age

Psychos

Psychos

Cognit

exual

ocial

ive

Infa

playing

since

with

he

clays.

was
sick.

Sch

(3) Right posterior hand


Infiltrated IV site
(4) Left foot IV infusion site
present.
Others

ool
Age

ncy
Tod
dler
Pre

Anal: the

Autonomy

Preop

sch

patient

VS

eration

ool

is

Shame

al:

already

and

The

potty

Doubt:

patient

trained

Engages

XYZ

in

wants

activities,

to

such as

control

coloring

the

books

chann

and

el

Body Map. (Illustrate in the body


map how your patint looks like e.g.
tubes inserted, bruses, srgial
incisions. Physical abnormalities,
affected areas. Mark with a small
x where it is loacated or draw it on
the body map and then label.
Describe Affected Areas:
(1) Mouth white lesions
present on the tongue;
cracked lips
(2) Abdomen abnormal

XII. LABORATORY/DIAGNOSTIC
RESULTS

enlargement of abdomen
7

(
2
)

LABORATORY AND DIAGNOSTIC


RESULTS

RBC
Hgb
Hct
A. Complete Blood Count
MCV
MCH
November 30, 2015
MCHC
Variables
Remarks
Platelet
WBC
High
Neutrophils
RBC
Low
Lymphocytes
Hgb
Low
Hct
Low
MCV
High
MCH
Normal
Monocytes
MCHC
Low
Eosinophil
Platelet
Low
Basophil
Neutrophils
Normal
ROW-CV
Lymphocytes
High

Monocytes
Eosinophil
Basophil
ROW-CV

Variables
WBC

Variables
WBC
RBC
Hgb
Hct
MCV
MCH
MCHC
December 1, 2015Platelet
Neutrophils
Remarks
Lymphocytes
High

Low
Normal
Normal
High

Low
Monocytes
Low
Eosinophil
Low
Basophil
High
RDW-CV
Normal
Normal
Low
B. URINALYSIS 11/30
Normal
Normal Physical Exam:

Normal
Normal
Normal
High

Color Yellow
Transparency Clear

Low
Normal Chemical Parameter
Normal
Specific Gravity 1.020
High
pH 6.5
Sugar Negative
Protein
December 2,
2015 Negative
RemarksMicroscopic/Urine Floucy
High
Low WBC 6/uL (Normal range: 0-11)
Low RBC High 100/ uL (Normal range:
Low 0-11)
High Epith. Cells FEW/uL (Normal
Normal range: 0-11)
Normal Cast 0/Ul (Normal range: 0-1)
Low BACTERIA PLENTY/uL (Normal
Normal range: 0-111)
Normal
8

BCG

C. XRAY 11/30
Chief Complaint: Fast breathing,
pallor

Hepa(3)

No discrete adenopathy is
identified.
Heart is not enlarged.
Hemidiaphragms and sulci are
intact.
Bony thorax is unremarkable.

DPT

Date

Place

ion

Received

Receiv

Center

mother

mother
Not

Health

remembe

Center

red by
mother
Not

Health

remembe

Center

red by
OPV

mother
Not

Health

remembe

Center

red by
Measles

mother
Not

Health

remembe

Center

red by

XIII. Immunizations Received


Immunizat

remembe

red by

red by

Findings:
Lung fairly aerated. Hazy opacities
are appreciated in both inner lung
zones with prominence of the
interstitial lung markings.

Impression:
Bilateral pneumonia. Concomitant
viral or reactive airways disease
cannot be entirely excluded as well
as interstitial edema.

Not

ed
Health

MR

mother
Not

Health

remembe

Center
9

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