Nursing History

Personal History
T.M was return to the nursing station, and has been admitted to the hospital. T.M is a 3 year old
boy with CP and have surgery for a femoral osteotomy and tendon lengthening to stabilize hip
joints. Currently residing at Sapang Bulac D.R.T Bulacan and was born on July 3 2001.

Chief Complaint
Consultation
Present Health History
3 years prior to admission, the patient mother noticed the head lag at 5 months of the patient, leg
scissoring, Right hand preference at 12 months and increasing irritability. Upon consultation, the
nurse determined the patient has impaired vision (wear glasses), speech impairment, seizure
disorder, and has poor weight gains and feeding issues since birth. Patient has not able to
ambulate without braces and wears AFO (ankle foot orthotics). He has skin level feeding device
(Mic-Key Button).
Past Health History+

The patient has history of head lag at 5 months old, leg scissoring and increasing
irritability. Patient diagnosed CP at his young age. Patient has experiencing seizures and stiffness
in his muscle.
Family Health History

Patient’s mother has asthma. Patient’s brother has mild septal defect and still alive. Her uncle
has diabetes mellitus. Patient’s grandfather died due to cancer (unknown) and her grandmother has
hypertension.

Socio-Economic History

The patient is a 3 year old boy diagnosed with a CP. Patient mother is a housewife
and her father is a welder. Their monthly income ranges from 4,000 to 6,000. Their daily
expenditures included food, water, electricity and allowance.

Home and Environment History

T.M resides at Sapang Bulac DRT Bulacan and they have their own house. The patient’s house is

a bungalow type and it has mixed materials of plywood and hollow blocks and has adequate

living space for the family. They get water on a deep well near their house. They live near the

barangay health center but quite far from hospitals, schools and other government institutions.

Nutrition History

The patient’s usual meal consists of liquids. Patient has feeding issues since birth

and poor weight gains. T.M has a skin level feeding devices (Mic-Key Button)

24 Hour Diet

DAY 1 DAY 2

(Pre-operative) (Post- operative)

BREAKFAST NPO Blender food

LUNCH NPO milk

DINNER NPO milk

Elimination History

Patient has not regular bowel movement pre-operative . The patient doesnt defecate well in

her condition which is undergo in post surgery and spica cast the both legs into hips.

Physical Assessment
 General Survey: receive patient after the surgery of femoral osteotomy and tendon
lengthening to stabilize hip joints.

Vital Signs
Temperature 36.7 C

Pulse Rate 104 bpm

Respiratory Rate 21 bpm

Blood Pressure 120/70

Jan. 24, 2020
Body Parts Normal Findings Actual Findings Remarks
Skin Varies from light to The skin is dry Normal
deep brown; uniform because of the mic
in color. key button.

Hair Evenly distributed; Evenly distributed; Normal

silky; no infection or slightly dry; no
infestation infection or
infestation

Nails Convex; curvature; Convex; curvature; Normal

smooth in texture; smooth in texture;
intact epidermis; intact epidermis;
capillary beds of 1-2 capillary bed of 2
seconds seconds
Skull and Face Rounded, Rounded, Normal
normocephalic and normocephalic and
symmetrical; smooth symmetrical; smooth
skull contour; skull contour;
symmetrical facial symmetrical facial
movements movements
Eyes Eyebrow evenly The both eye is abnormal
distributed, skin intact; visually impaired
 eyebrows issues.
symmetrically aligned;
equal movement;
Equally distributed
eyelashes, curled
slightly outward; skin
intact, no
discoloration, no
edema, no tearing;
pupil black in colour,
equal in size

Ears and Hearing Colour same as facial Colour same as facial Normal
skin; symmetrical, firm skin; symmetrical,
and not tender; pinna firm and not tender;
recoils after it has pinna recoils after it
been fold; normal has been fold;
voice tone audible normal voice tone
audible
Nose and Sinuses Symmetric and Symmetric and Normal
straight; no discharge; straight; no
no flaring; not tender; discharge; no flaring;
no lesions; mucosa not tender; no
pink; nasal septum lesions; mucosa pink;
intact and in midline nasal septum intact
and in midline

Mouth and Lips uniform, pink in Lips uniform, pink in Fluid deficiency
Oropharynx color, soft; moist in color, dry; chapped
texture; inner lips and lips; inner lips and
buccal mucosa uniform buccal mucosa
pink; tongue central in uniform pink; tongue
position, moist, pink in central in position,
colour; smooth tongue moist, pink in colour;
 base with prominent smooth tongue base
veins; light pink uvula with prominent
position in midline. veins; light pink uvula
position in midline.
Neck Muscle equal size; Incision site; Underw+++ent
coordinated smooth
Muscle equal size; trunk procedure
movements with no
limited movements
discomfort; equal Incision site
with discomfort;
strength; no masses;
no lesions
Thorax and Lungs Spine vertically Spine vertically Difficulty of breathing
aligned; straight spinal aligned; straight related to pain
column; respiration spinal column;
rhythmic and effortless respiration
dysrhytmic and with
effort
Breast and Axillae Rounded in shape, Rounded in shape, Normal
uniform skin colour; uniform skin colour;
smooth and intact smooth and intact
skin; no masses or skin; no masses and
tenderness tenderness

Abdomen No masses, no lesions; The abdomen has Feeding Problem

no evidence of mic key button since Issues since birth.
enlargement of spleen birth.
and liver; audible
Mic key button
bowel movements;
feeding
symmetric contour

Upper and Lower Intact skin, uniform in The upper and lower Involuntary
movement of muscle
Extremities colour; smooth and extremities is intact,
due to Cerebral Palsy
coordinated the movement is not condition.
movement; no masses; coordinated and
no tenderness seizure.
 Diagnostic Exams

HEMATOLOGY Date: Jan. 4, 2020

LABS NORMAL VALUES ACTUAL VALUES SIGNIFICANCE

HEMOGLOBIN M: 135-160 g/L 141.0 g/L Normal

F: 120-150 g/L

HEMATOCRIT M: 0.40-0.48 0.475 Normal

F: 0.37-0.45
WBC COUNT 4.0-11.0 X (10) 9TH 10.53 X (10) 9TH Normal

LYMPHOCYTES 20.0-40.0 33.8 Normal

MONOCYTES 0.02-0.06 8.2 Normal

EOSONOPHILS 0.5-5.0 3.3 Normal

BASOPHILS 0.0 0.0-1.0 Normal

BLOOD TYPE B POSITIVE

MCV 76.0-88.0 fL 91.1 Fl Normal

MCH 27-34 pg 27.1 pg Normal
MCHC 320-360 g/L 297g/L Normal
RDW-CV 11-16 % 12.9 % Normal

PLT 150-450 (10)9th 333 (10)9th Normal

BLOOD CHEMISTRY Date: Jan 4, 2020

 NORMAL VALUES ACTUAL VALUES SIGNIFICANCE

BLOOD UREA NITROGEN 7-20 mg/dl 7.98 mg/dl Normal

SODIUM 133-143 mg/dl 135.60 mg/dl Normal

POTASSIUM 3.4-5.5 mg/dl 3.85 mg/dl Normal

CREATININE 58.00-96.00 mmol/L 66.98 mmol/L normal

URINALYSIS Date: Jan. 04, 2020

NORMAL VALUES ACTUAL VALUES SIGNIFICANCE

COLOR amber Straw Normal

SPECIFIC GRAVITY 1.001-1.035 1.005 Normal

RBC 0-2 0.2 Normal

WBC 0-2 0.2 Normal

BACTERIA Few Normal

TRANSPARENCY Clear Normal

ACTIVATED PARTIAL THROMBOPLASTIN TIME Date: Jan 22, 2020

NORMAL VALUES ACTUAL VALUES SIGNIFICANCE

APTT 25-43 sec 43.8 Normal

CHEST X-RAY

RADIOLOGICAL FINDINGS:

The lung fields are clear with normal vascular pattern.

The heart and the great vessels are with in normal limits.

The diaphragm and bony thoracic structures are intact.

No other remarkable findings.