NURSING PROCESS
A. ASSESSMENT
1. PERSONAL DATA
Patient Exbi is a 12 year old male child , 3rd youngest among 9 siblings,
resides at San Isidro, San Fernando, Pampanga. He is a Filipino citizen, born on
November 5, 2005 at a tertiary hospital (JBLMRH). His mother and father are
both Filipinos and are devoted members of the Roman Catholic Church.
Patient Exbi was admitted January 14, 2018 and was discharged January
18, 2018 with a final diagnosis of Acute Glomerulonephritis.
3. PERSONAL HISTORY
Chief complaint of the client, as stated: “mainit yung tyan konti.” Also with
signs and symptoms of headache and vomiting. Symptoms started on January
10, 2018, “sa bahay nagstart sumakit yung tyan”, verbalized by the client. And
after a few days, 1/14/18, he was admitted. It suddenly occurred, the number of
times the client’s abdominal area hurts is around 3-5 times a day, lasting about
30s, as stated by the client. The client rated the pain as 7 or 8 out of 10, he then
described the pain as sharp or stabbing pain. It occurred when he was walking
outside with his friends, roaming around their place. Symptoms associated with
the complaint are as follows: headache and stomachache. Factors that
aggravate or alleviate the problem as verbalized by the client and SO, “sa pag
galaw-galaw” and “malikot kasi siya.”
6. PHYSICAL EXAMINATION
Starting from the head, the client’s hair color is black, is thick and long and
distributed evenly around. As inspected and palpated, the scalp has no signs of
any lice, has no presence of any wounds, lacerations, or abrasions. But has
presence of some dandruff. Ears have no presence of any tears, lacerations, or
injuries. It has minimal amount of earwax. Mouth and tongue are moist and pink.
Neck has no presence of any injuries. Peripheral extremities, as inspected and
palpated, are normal. It does not have any signs of injuries. Nails appeared to be
a little dirty and long.
Appearance of the client are as follows: has a small body frame, stands 4
feet 5 inches, weighs around 24.6-24.7kgs, skin appears to be dark, dry, has
good skin turgor, posture of client when sitting is poor, always slacking or in a
slouching position, walks consciously and straight. In terms of hygiene and
grooming, the client is a 6 out of 10. Facial expressions show accordingly to the
mood and situation. Breathing well, respiratory rate is in normal range.
Mental status of the client are as follows: Clients attitude is not that good,
he does not listen when being ask, does not cooperate very well. Mood of the
client is not consistent, there are times that he is upbeat and at times he is
mellow. In terms of the client’s appropriateness to respond, he is not complying
to what is being done. Quality of speech is rated as 6 out of 10. Quantity of
speech is rated as 6.5 out of 10. Clarity is rated as 5 out of 10. Coherence is
rated at 6 out of 10. Vagueness of the client is rated at a staggering 8 out of 10.