School health record

Pupil name Farah Ahmed Ali Age : 10 Sex: female

Date of attendance to clinic: 9-11-2021
Reason of attendance to clinic: Abdominal pain
Socio-economic characteristics
Father Education Illiterate or read and write ( - ) Primary ( - )
Preparatory ( - ) Secondary ( - ) University ( )
Mother Education Illiterate or read and write (- ) Primary ( - )
Preparatory ( - ) Secondary (-) University ( )
Father occupation Don’t work (- ) Worker ( ) Clerk (- ) other (- )
Mother occupation House wife (- ) Worker () Clerk ( - ) other (- )
Income / month Not enough (- ) Enough () Enough and save (-)
Number of sisters &brothers Males (2) Females (4)
Total number of household members= 9
Number of household bedrooms= 3
Crowded ratio= 9/3= 3 Interpretation:Overcrowded
environment and suspected for
airborne infectious disease
Present health history
Chief complaints Abdominal pain
Onset: gradual Frequency: Intermittent
Duration: 2days ago
Date of starting medical treatment: 9-11-2021
Current medication Name: Voltaren Dose:75 Route of administration: IM
mg/ml
Associated signs & symptoms: No Associated Sign and symptoms

Past health history:

Accident ( - ) Allergy ( - ) Blood transfusion (- ) Kidney
disease(- )
Heart disease(- ) Diabetes mellitus (- ) Respiratory disease (- ) Others ( - )

Physical assessment:
Vital signs Temp: - Pulse: - Resp: -

Anthropometric measurements
Wt: 30kgm Ht:1,2 m Interpretation:
Body mass index:20,8 Normal body weight.
General appearance
Eye: Redness ( - ) Squinting (- ) Discharge (- ) Wear eye glasses ( - )
Ear: Impaired hearing ( - ) Discharge ( - ) Ear ache (- )
Nose and throat: Nasal discharge ( - ) Epistaxis ( - ) Sore throat (- )
Oral cavity: Lips: Dryness (- ) Pale (- )
Gum: Inflammation (- ) Bleeding ( - ).
Dental problem: Decayed ( ) Missed ( ) Filled ( - ) Malocclusion (- )
Lab investigations:
Radiological examination:
Nursing Diagnosis
1-Moderate intermittent Abdominal pain (Alteration of comfort in abdomen ) related to
eating contaminated food as evidenced by patient’s complaints
2- Deficit knowledge about teeth hygiene related to not available information about teeth
hygiene as manfested by yellow teeth and teeth decay.
 Nursing care plan
Date of Health problem Assessment Nursing Health education Progress Follow up
visit intervention
9-11- Abdominal pain ✓ Assess • Place child in ➢ Avoid eating from any Pain is Follow the child’s
2021
charactrstic comfortable restaurant out side home relieved condition and
10.00 of pain position reassess the pain
AM
PQRST ➢ Ensure food is good
• Provide warm cooking and prepared
✓ Assess the
fluid to
Nursing Diagnosis
child ➢ Regulary hand washing to
relieve pain
condition prevent pollution
Moderate Intermittent
✓ Assess the • Place warm
Abdominal pain ➢ Don’t eat from street
child towel on
( alteration of comfort in
ability to abdomen to ➢ Ensure washing raw food
Abdomen)
deal with relieve pain before eating
Related to eating contaminated pain
• Provide ➢ Don’t eat snack food
food as evidenced by patient’s
✓ Assess the comfort
complaints psychological ➢ Don’t eat any food not
environment
state of
to relieve cover
child.
stress
 Nursing care plan
Date of Health need Assessment Nursing Health education Progress Follow up
visit intervention
9-11- Health education about ✓ Assess the . • Clean the teeth after every meal Gain all Follow the
2021
teeth hygiene ability of information child’s
• Prevent eat much sugar
10.30 child to eat About teeth condition and
AM • Wash the teeth by using good Hygiene Ensure
✓ Assess the
toothbrush hygiene
teeth
Nursing Diagnosis of teeth.
appearance • Don’t use any thing not medical
Deficit knowledge about of child to clean the tooth
teeth hygiene related
not available ✓ Assess the • Don’t drink very cold or hot
information about teeth routiene of drink
hygiene as manfisted by
yellow teeth and teeth decay. washing
• Keep the teeth clean before
teeth
sleep

• Drink milk to increase healthy of

Teeth.