NURSING ASSESSMENT II

Name: Patient X Age: 7 M/O Sex: F

Admitting Chief Complaint: Seizure, fever, cough, convulsion
Impression/Diagnosis: Status Epilepticus Inclusive Dates of Care: 10/06/22
Date/Time Admission: 10/06/2022 Allergies: None
Diet: None
NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL CLINICAL APPRAISAL
DAY 1 DAY 2
1. ACTIVITIES- REST The patient loved doing activities The patient was weak and most of the The patient is not that weak anymore, The patient’s condition was improved
a. Activities such as thumb sucking and was very time she can’t move freely. The conscious and was lying on a and can move just enough but can’t
b. Rest jolly. She also liked watching patient mostly sleepy in the morning hammock. The patient can’t also move perform some activities yet. Her sleeping
c. Sleeping Pattern nursery rhymes videos. The patient and wakes up for a couple of hours her body from side to side and can’t pattern was not disturbed also and can
takes a nap at least 4 to 5 hours and then sleep again in the evening. normally sleep well. sleep well.
during daytime and usually sleeps
around 9pm in the evening.
2. NUTRITIONAL- The patient has a good appetite and The patient still drinks formula milk Usually, the patient drinks 4 to 5 The patient still drinks formula milk and
METABOLIC usually drinks 4-5 bottles of formula but has reduced the amount to only 2 bottles of formula milk per day. Due to has improved the amount taken. The
a. Typical intake (food, milk per day. Due to the patient’s to 3 bottles of milk per day. Patient the patient’s age, she cannot eat other patient cannot eat food other than the
fluid) age, she can’t eat other kinds of food still cannot eat food other than the kinds of food yet and only relies on the formula milk provided. She has no diet
b. Diet yet and only relies on the nutrients milk fed to her daily. She has no diet nutrients given by the formula milk. restrictions. Patient did not lose weight
c. Diet Restrictions given by the formula milk. The restrictions still. Patient lost weight The patient gains weight easily and was taking medicine to treat her
d. Weight patient didn’t take vitamins or and was taking medicine to gain her according to her mother and illness.
e. medicine also. strength back. does not take vitamins or other
Medications/Supplement medications.
food

3. ELIMINATION Patient voids frequently and changes Patient voids less frequently but the Patient voids less frequently but diaper Patient voids frequently and the diaper
a. Urine (frequency, diaper every 3 to 6 hours. Urine is diaper used is still changed every 5 to still changed every 5 to 7 hours. Urine has been changed 4 times. The color of
color, transparency) clear and yellowish in color. Bowel 7 hours. Urine is clear and light is still clear and light yellow in color. the urine is light yellow. The patient
b. Bowel (frequency, movement on the other hand is
color, consistency) normal and defecates 2 to 4 times a
day. The color of the stool was
always yellow and is not watery nor
loose.
4. EGO INTEGRITY Patient is always with her family and
a. Perception of self was very playful and relies on her
b. Coping Mechanism family a lot. The patient is well-
c. Support System taken care of by her family.
d. Mood/Affect Moreover, the baby rarely cries and
loves to wear smile, may it be
toward a stranger or not.
5. NEURO-SENSORY The patient is in good terms with her
a. Mental state family. She often cries when put on
b. Condition of five the hammock which indicate that the
senses: (sight, hearing, patient is in a good mental state.
smell, taste, touch) Patient’s five senses are functioning
as well: Patient was able to focus on
certain objects, responds
immediately when being touched
and smiles when she sees new
people.
6. OXYGENATION The patients show sudden ineffective The patient’s vital signs at 6pm are the The patient’s vital signs at 9pm are the
a. Vital signs breathing pattern. Lung sounds following:
Temperature seems abnormal and patient was not
Respiratory rate Heart checked whether she has respiratory
rate Blood Pressure problems until she was hospitalized
yellow in color. During the 8 hours of During the 8 hours of shift the diaper of soiled the diaper one time, and the color
shift the diaper of the patient was the patient was soiled and the color of of the stool is yellow and was neither
soiled and was changed. the stool is yellow. watery nor loose.
Patient is usually taken care of by her Patient is usually taken care of by her The patient’s mother feels that she lost
mother and father and usually relies mother and father and usually relies on weight and now appears unhealthy.
on them. Similarly, she remains jolly them. She remains jolly and only cries Patient is usually taken care of by her
and only cries whenever she feels pain whenever she feels pain on the site mother and father and usually relies on
on the site where the cannula is where the cannula is attached them. During the 8-hour shift, she was
attached and if she’s not comfortable specifically on the right side of her also visited by her father. Similarly, she
in her position. dorsal venous plexus of the foot. remains jolly and smiles often. She also
did not cry that much.
Patient is often smiling and only cries
Patient is not in mental distress and The patient remains in a good mental
when she feels pain on the site where often smile. She only cries when she state as evidenced by consistent smiling
the cannula is attached, specifically on
feels pain on the site where the cannula toward her parents and to other people.
the right side of the dorsal venous is attached, specifically on the right Patient rarely cries. Patient shows signs
flexes of the foot. Patient shows signs
side of the dorsal venous flexes of the of having good senses in line with her
of having good senses in line with herfoot. Patient shows signs of having age. Patient was able to focus on certain
age. Patient was able to focus on good senses in line with her age. objects, responds immediately when
certain objects, responds immediately Patient was able to focus on certain being touched and smiles when she sees
when being touched and smiles when objects, responds immediately when new people.
she sees new people. being touched and smiles when she
sees new people.
The patient’s vital signs at 9pm are the
following: following:
T: 36.6 ℃ T: 36.5℃ T: 36.3 ℃
PR: 104 bpm PR: 108 bpm PR: 103 bpm
RR: 54 cpm RR: 53 cpm RR: 40 cpm
b. Lung sounds because of fever, convulsion, and O2Sat: 98% O2Sat: 98% O2Sat: 98%
c. History of Respiratory difficulty in breathing. There is presence of adventitious There is presence of abnormal breath There is presence of abnormal breath
Problems breath sounds, specifically crackles. sounds, specifically crackles. The sounds, specifically crackles. The patient
The patient was diagnosed with status patient was diagnosed with status was diagnosed with status Epilepticus.
Epilepticus. After conducting several Epilepticus. After conducting several After conducting several diagnostic tests,
diagnostic tests, the patient has been diagnostic tests, the patient has been the patient has been diagnosed with
diagnosed with PCAP D. diagnosed with PCAP D. PCAP D.
7. PAIN-COMFORT Patient had an onset of Patient feels pain on the site where the Patient feels pain on the site where the Patient feels pain on the site where the
a. Pain (location, onset, nonproductive cough. The patient is cannula is attached, specifically on the cannula is attached, specifically on the cannula is attached, specifically on the
character, intensity, suspected to feel chest pain during right side of the dorsal venous plexus right side of the dorsal venous plexus right side of the dorsal venous plexus of
duration, associated her nonproductive cough. The of the foot. She reacts when the gauze of the foot. She reacts when the gauze the foot. She reacts when the gauze
symptoms, aggravation) patient was given salbutamol for bandage attached is charged. This is bandage attached is charged. This is bandage attached is charged. This is
b. Comfort nebulization and chest rubs to ease indicated by crying and facial grimace indicated by crying and facial grimace indicated by crying and facial grimace
measures/Alleviation the pain in the chest. when the site of attachment is moved when the site of attachment is moved or when the site of attachment is moved or
c. Medication or cleaned. cleaned. cleaned.
8. HYGIENE AND Patient is an infant and was provided Patient is an infant and is rarely given Patient is an infant and is rarely given a Patient is an infant and was usually given
ACTIVITIES OF with proper hygiene with her mother. a bath due to the attachment of the bath due to the attachment of the a bath seldomly because of the IV
DAILY LIVING She is given a bath everyday around cannula at the dorsal plexus of the cannula at the dorsal plexus of the foot. cannula attached at dorsal plexus of the
9 to 10 AM. Her activities include foot. Instead of daily baths, the patient Instead of daily baths, the patient is foot. Patient usually smiles and often
kicking her legs, sucking her thumb, is wiped with wet cloth every morning wiped with wet cloth every morning to cries when put on the hammock.
and wiggling of fingers. to ensure sanitation and promote ensure sanitation and promote hygiene.
hygiene. Patient is still active and does Patient is still active and does similar
similar activities that she usually does activities that she usually does before
before hospitalization. hospitalization.
9. SEXUALITY Patient is a 7-month-old infant, Patient is a 7-month-old infant, Patient is a 7-month-old infant, female. Patient is a 7-month-old, female.
a. Female (menarche, female. female.
menstrual cycle, civil
status, number of
children, reproductive
status)
b. Male (circumcision,
civil status, number of
children)