BIOGRAPHIC DATA Name: Client G.D.C Address: BO San Lazaro Tala Caloocan City Age: 2 mos.

old Gender: Male Date of birth: August 2, 2011 Chief Complaint: Difficulty of Breathing Provisional Diagnosis: Acute Bronchitis r/o Sepsis Religion: Born Again Christian Primary Care Provider: Arlene Dela Cruz Informant: Arlene Dela Cruz Informants Relationship: Grandmother Date of admission: September 27, 2011 at 7:45 A.M.

The patients grandmother is the one taking care and providing for him since his parents are both too young and not married. NURSING HISTORY A. History of Past illness This is the patients first admission. He already received vaccines such as: BCG, DPT, Hepatitis. The second dose for Hepa. and DPT was scheduled last September 29, 2011 but wasnt done since the patient is currently admitted in the hospital. B. History of Present Illness Two days prior to admission, the patient has positive cough with difficulty of breathing, persistence prompted to consult and be admitted. C. Family History When it comes to the family history, the grandmother stated sa side naming, may asthma ako tsaka yung anak ko, yung tatay nya. Meron din kaming highblood. Dun sa side ng nanay niyan.

ADL Before the client was admitted to the hospital, the client wakes up at around 7 in the morning, have his bath around 9 A.M. Then the patient returns to his sleep. Before his mother left their house she was the

one feeding the patient for about 20 minutes. The grandmother verbalized noon kasi nung nasa bahay pa ang ina nyan, sinubukan syang padedehan kaso talagang kaunti lang ung gatas na lumalabas kaya Bona na lang yung pinadede namin mga 2-3 oz. every 2 hours. Sinimulan naming yang siguro mga dalawa o tatlong lingo na ang nakaraan simula nung nagka-problema nga sa nanay niyan

Nutrition The clients grandmother verbalized dumedede yan sa ina nya noong mga ilang linggo pa lang sya. Kaso konti lang yung gatas na lumalabas dun sa babae na yun, hindi kasi kumakain ng gulay. Simula noon Bona na lang ipina-dede namin. Ok naman sya dumede malakas naman. Ako nags.suporta sa mga pangangailangan nya kasi walang trabaho yung ama. Disi-Sais pa lang kasi yun anak ko, tas yung nanay niyan e 19.

Rest and Sleep Before the patient was admitted the informant stated mahaba yang matulog, ganun naman talaga pag baby matakaw sa tulog. Gigising yang ng mga 7 A.M papaliguan tapos dedede, pagkatapos tutulog na ulit. Talagang gumigising lang pag nagugutom. Prior to admission, it was observed by the informant that the patient wasnt able to sleep well, she added noong napansin ko na nagka-ubo sya, nagsimula na syang magligalig at mawalan ng gana dumede. Iyak lang sya ng iyak na parang hirap huminga. Hindi na rin sya nakakatulog ng maayos e. Kawawa nga kasi napaka-liit pa para magka-ganyan. Hygiene The client is bathed once a day with luke-warm water. It takes only about five-ten minutes and they are using baby soap. The informant stated talagang nililinis din naming mga gamit niyan. Yung higaan, mga damit, kasi nga baby. Kaso yung ina niyan pag kinukuha sya at inuuwi sa bahay nila e napapabayaan, ni hindi mapalitan ng damit. Pinapabayaan na lang mtuyuan ng pawis at igina-gala, kaya asar na asar ako. Elimination The informant stated the clients stool is formed, yellowish in color. She stated that that the client usually eliminates once every two days. The informant verbalized that the clients urine is light yellow in color however it becomes bright yellow due to the vitamins she takes. The informant stated gumagamit kami ng diaper mga dalawang beses lang sa isang araw tapos maghapon na syang nakalampin. Kawawa kasi ang bata pag naka-diaper palagi kasi mainit yun e.