Patient’s Profile

Name : Patient X
Age : 4 years old
Gender : Male
Ethnic Background : Kankana-ey
Civil Status : Single
Religion : Jehovah’s Witnesses
Occupation : Not Applicable

Admitting Diagnosis : Pneumonia

Final/Principal Diagnosis : Bacterial Pneumonia
Date and Time Admitted : November 1, 2021, at 10:00 am

13 Areas of Assessment

1. Psychosocial and Psychological Status

Patient X is a 4-year-old male and a resident of Bauko, Mountain Province. His religion is Jehovah’s
Witness. Their religion believes that it is against God’s will to receive blood and, therefore, it is one of their
rules to not receive any blood transfusions.

2. Mental and Emotional Status

The patient is awake and alert but in moderate distress.

3. Environmental Status
The patient is a resident of Bauko, Mountain Province and the family lives in a 2-storey concrete house with 3
rooms. The patient spends most of his time playing around and is mostly being brought to OPD for check-up during
time of illness. They live beside the highway where it is possible that air irritants from smoke coming from vehicles
puts him at higher risk of acquiring bacterial pneumonia.

4. Sensor Status
a. Visual Status
There is no known visual deficit like color blindness and blurred vision.

b. Auditory
No corrective auditory deficits and no auditory device noted being used by the patient. He can
also distinguish voices.

c. Olfactory Status
There is the presence of nasal flaring. The patient cannot distinguish an odor due to excessive
mucus in his nasal cavity.

d. Gustatory Status
The mother stated that his solid intake was decreased more likely cause by alteration in taste
because of excessive mucus production.
e. Tactile Status
He can perceive heat, cold, pain with regards to stimulus, he is also able to differentiate common
objects by touch and able to discriminate light and firm touch.

5. Motor Status
Patient is on sitting position with slightly limited movement. He has muscle strength of 3/5 on
both upper and lower extremities, which means that he has limited movement against gravity and
some resistance. Furthermore, no tremors and deformities noted on both upper and lower extremities.
Upper extremities are symmetrical as well as the lower extremities. Peripheral pulses were present
such as radial pulse. No crepitus noted upon flexion of joints. Extremities are warm to touch.

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Thermoregulatory Status
Date Time Temperature Findings and
Implications

November 2, 2021 7 am 40 The body becomes weak

and there is an
11 am 38.5
inflammation in the air
3 pm 38.8 sacs which causes fever
7 pm 38.8

November 3, 2021 7 am 38.6 The body temperature

dropped due to intake
11 am 38.4
of acetaminophen IV
3 pm 38 every 4 hours.
7 pm 37.9

The patient’s temperature on November 2, 2021, at 7 am-7 pm increased from 40C-

38.8C (patient has a high fever). And the patient’s temperature on November 03, 2021, at 7 am
to 7 pm decreased from 38.6-37.9 (patient still has fever).

6. Respiratory Status
Date time RR Findings and
Implications

November 2 7 am 34 cpm The air sacs are filled up

with fluid or pus, which
11 am 38 cpm
leads to difficulty of
3 pm 40 cpm breathing and chest pain.
7 pm 36 cpm

November 3 7 am 34 cpm The RR of the patient

decreased to normal.
11 am 35 cpm
3 pm 36 cpm
7 pm 30 cpm
The patient’s RR on November 2, 2021 at 7 am-7 pm are above normal range (normal range
is at 25-30 bpm). And the patients RR on November 3, 2021 at 7 am-7 pm decreased and
was at normal reading at 7 pm.

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7. Circulatory Status
Blood pressure is 100/70 mmHg. His pulse has a regular rhythm, but the capillary
refill is delayed with a time of 3 seconds.

8. Nutritional Status
He is a picky eater; he loves to eat sweet foods likes chocolates and candies. He
consumes 2 glasses of milk and an average of 4 glasses of water every day. During his
confinement, the mother has noticed decreased fluid intake from an average of 4 to only 3
glasses daily. His solid intake also decreased possibly due to loss of appetite and loss of
sense of taste.
9. Elimination Status
The patient continued to take liquids well, but his solid intake was decreased, the
patient has lost his appetite which is a symptom of pneumonia. Episodes of vomiting was
also mentioned by his mother which is not a normal route for elimination. He was able to
excrete stool on his first day of confinement (November 1, 2021) and is voiding well.

10. Sleep, Rest and Comfort Status

The patient only sleeps for at least 5-6 hours due to discomfort and in moderate
distress. He does not need to take nap at daytime because lying flat most of the time on his
back for a long time can increase risk of pneumonia to worsen.

11. Fluids and Electrolytes Status

The patient consumes 2 glasses of milk and an average of 4 glasses of water every
day. Excess loss of water and electrolytes from the body is caused by episodes of vomiting
by the patient. The patient was given an IVF of BMMS 500 mL x 8 hours and the current
level was at 350 mL with the same IVF to follow with an hourly rate of 12 hours. When
sodium level is low it can cause loss of energy, fatigue, and muscle weakness which is
visible in the patient.
12. Integumentary Status
Due to airway obstruction from excessive mucus, the patient’s capillary refill is 3
seconds. Ho wever, when managed, he appears to be pinkish in color but with poor skin
turgor due to d ehydration from episodes of vomiting.