II.

Nursing Assessment

1. Personal Data

a. Demographic Data

Name: Carl Vincent Velasquez

Age: 6 Years Old

Name of Parents: Noel Velasquez (Father)

Aneth Velasquez (Mother)

Address: San Agustin, Arayat, Pampanga

Date of Birth: September 21, 2003

Place of Birth: Dr. Emigdio C. Cruz Sr. Memorial Hospital, Arayat, Pampanga

Nationality: Filipino

Date of Admission: December 09, 2009

Date of Discharge: December 12, 2009

Informant: Aneth Velasquez (Mother)

 2. Family Health History

a. Genogram

Noel
Aneth

Carl Dirk

LEGEND:

- Male
- Pregnant (6 months)

- Female
- Acute Tonsillopharyngitis

- Deceased

- Heart Disease

- Vehicular Accident
 b. Size of Family: Medium. There are four people who comprise the family and a

newborn baby is about to come. Mrs. Velasquez is six months pregnant with her

third child.

c. Obstetrical History: G3 P2 T2 P0 A0 L2 M0

Name of Date of Mode of Place of Complications Birth Age of

Child Delivery Delivery Delivery weight Gestation
Carl September Normal Arayat, None 5.6 lbs 38 months
Vincent 21, 2003 Spontaneous Pampanga
Delivery
Dirk July 16, Normal Arayat, None 5.2 lbs 39 months
2006 Spontaneous Pampanga
Delivery
Baby Currently at 6 months
Girl 6 months
Age of ----- ----- ----- -----
Gestation

d. Economic Status

Economically Productive Member Type of Occupation Income per month

Noel Velasquez Teacher 15, 000

Living Condition
Type of House: Single Detached

Factors that may Affect Health: Eating sweet foods like candies, chocolates and

cakes. Patient is also fond of sharing drinks with his classmates and playmates.

According to Mrs. Velasquez, the patient won’t drink unless it is a soda or a juice. If

there are no fizzy or concentrated drinks available, the patient would wish to have ice

cold water.

e. Health Attitude and Factors Affecting Health of Family

Religion: Roman Catholic

Family Tradition: The Velasquez Family uses herbal medicines in replace to the

modern way of treating illnesses and sickness. Medicines are sometimes expensive

that is why they cling to the traditional treatment.

3. Personal History

a. Practices and Habits of Mother during pregnancy

Mrs. Velasquez eats plenty of fruits during pregnancy because she believes that it will

help the baby develop a good skin complexion. She also walks for about ten minutes

every morning to exercise her back and to get some fresh air. When she’s pregnant,

she does not engage in cooking that much because she becomes very sensitive with

the smell of food especially to the spices.

b. Feeding Process

Mrs. Velasquez always breastfeed her children because she believes that the best milk

does not come from formula milk but from the mother.
c. Growth and Development (Client-Centered)

Age: 6 years old

Freud’s Psychoanalytic Theory: Phallic Stage

Erikson’s Theory of Psychosocial Development: Initiative VS. Guilt

Kohlberg’s Theory of Moral Development: Pre-conventional Stage II

Piaget’s Theory of Cognitive Development: Perceptual Intuitive Stage

d. Immunization

Child Immunization

Carl Vincent already had vaccines for BCG, Hepa B, OPV, DPT and Measles. He is a

Fully Immunized Child. Due to infection, he also had Tetanus Toxoid vaccine last

December 11, 2009.

Maternal Immunization

Mrs. Aneth Velasquez already had her 5 shots of Tetanus Toxoid. She is six months

pregnant now and she had her latest vaccine last December 11, 2009.

4. History of Past Illness

The patient was never hospitalized before. He never had serious illness such as

mumps, chicken pox and dengue. He has fever and colds most of the time.

5. History of Present Illness

The patient is having Acute Tonsillo-pharyngitis. According to his doctor, Carl

acquired it from eating sweet foods and drinking cold drinks. It started on December

5, 2009 as a simple sore throat and then last December 9, 2009 the patient started

throwing out every single food he takes. He vomits most of his stomach contents.

This is also the day when he was confined at Dr. Emigdio C. Cruz Sr. Memorial

Hospital and was diagnosed of having Acute Tonsillo-pharyngitis.

6. Physical Examination

a. Skin, Hair and Nail Assessment

Skin- color is brown, texture is soft and smooth, temperature is warm. When the skin

is pinched it returns immediately to original position. There is no swelling, pitting or

edema. There are no skin lesions detected.

Hair- texture is fine and pliant. There are no presence or signs of parasitism.

Nail- nail beds are pink, shape is round, hard and immobile.

b. Head, Face and Neck Assessment

Head- symmetrical in shape and round.

Face- symmetrical, centered head position.

Neck- smooth, controlled movements.

c. Eye Assessment
Lid margins are moist and pink. Lashes are long, evenly spaced and curled outward.

Lower margins at bottom edge of iris, upper margins of lid covered approximately of

iris.

Bulbar conjunctiva is clear, no discharge seen.

Sclera is white.

Cornea is transparent, smooth and moist.

Iris are round and equal in shape, color is black.

Lens are clear

d. Ear Assessment

External ears are of equal size and similar appearance, nontender. No presence of

lesions.

Mastoid process is nontender, warm and easily palpated.

Auditory canal has brown discharge with a soft consistency and has no odor.

e. Mouth, Throat, Nose and Sinus Assessment

Mouth- lips are red and dry, no lesions and swelling. Buccal mucosa is reddish and

hot to touch, smooth and moist without lesions. Gums are also pink, moist and

clearly defined margins. There are 17 deciduous teeth, fixed and yellowish. Tongue

has white curds on surface and reddish, moist and symmetrical in appearance.

Tonsils are red and with a grade of 2+.

Nose- brown in color, consistency is smooth, symmetrical in appearance, dry with

crusting, with greenish discharge, septum is in the midline and no lesions.

Sinus- nontender on palpation, hollow tone elicited.

f. Chest and Lung Assessment

Chest- color is pink, intercostals spaces are even and relaxed, chest is symmetrical,

and sternum is on the level with the ribs. Upon palpation there are no reported pains

or tenderness.

Lungs- there are no murmurs and crackles heard upon auscultation.

g. Breast Assessment

Breast is symmetrical in shape with slight variation, pink in color and smooth.

Areola and Nipples are round and relatively the same, brown in color, no discharge

present. Temperature is warm.

h. Heart Assessment

Apical Pulse is 98 beats per minute and Radial Pulse is 98 beats per minute. Both

pulses are symmetrical and equal rate, strength and rhythm.

i. Peripheral Vascular Assessment

Upper extremities- pink in color and warm. Client can identify light and deep touch,

nontender, mobile and bilateral pulses are strong and equal.

Jugular veins- pink in color, warm and mobile. There is light venous distention, skin

in intact, there is no edema and bilateral pulses are strong and equal.
 Lower extremities- pink in color and warm. Client can identify light and deep touch,

nontender, mobile and bilateral pulses are strong and equal. No verbalization of calf

pain or soreness.

j. Abdominal Assessment

Skin color is brown, no rashes or lesions. Umbilicus is sunken and pinkish. Abdomen

is flat and symmetrical. Vascular sounds no bruits, no venous hums, no friction rubs.

k. Musculoskeletal Assessment

Patient was not able to stand up because of body malaise. The student nurses

were not able to assess her musculoskeletal built.

l. Neurological Assessment

Patient is relaxed, coherent and conscious.

Cranial Nerve Assessment Technique Client’s Response

CN I – Olfactory The client is asked to identify the Client identifies correctly with
scent of a perfume while eyes are each nostril
closed.
CN II – Optic The client is asked to read the Client reads print at 14 inches
printed material written on an without difficulty.
illustration board
CN III – Oculomotor Using an opaque card, the client is Client’s eyes move in a
asked to follow the four cardinal smooth, coordinated manner in
movements. all directions.
CN IV - Trochlear Using a pen light, the client is asked Client’s eyes move in a
to focus eyes on a straight direction.smooth, coordinated manner in
all directions.
CN V – Trigeminal The examiner uses a cotton bud tip Client identifies light touch,
to let the client identify light touch, dull, and sharp sensations to
and a paper clip to identify dull and forehead. Cheeks and chin.
sharp sensation while eyes are Masseter and temporal
closed. For the assessment of the muscles contract bilaterally.
 masseter and temporal muscles, the
client is asked to clench teeth as if
she is biting something.
CN VI – Abducens Using a pen light, the client is asked Client’s eyes move in a
to focus eyes on a straight direction. smooth, coordinated manner in
all directions.
CN VII – Facial The client is asked to identify bitter, Client identifies taste correctly
salty, sweet and sour taste.
CN VIII – The client is asked to repeat the Client is able to hear
Vestibulocochlear words whispered the by examiner. whispered words 1-2 feet
Also, the client is asked to close eyes
to test for equilibrium (Romberg’s
Test).
CN IX – The client is asked to identify Client identifies taste and gag
Glossopharyngeal calamansi juice and salt on posterior reflex present
one third of tongue with eyes closed.
CN X - Vagus The client is asked to open mouth Bilateral, symmetrical rise of
and the examiner touched the back soft palate and uvula
of tongue using tongue depressor.
CN XI – Accessory The client is asked to shrug Symmetrical, strong
shoulders against resistance of the contraction of trapezius
examiners hands. For the muscles. Sternocleidomastoid
sterocleidomastoid, the client is can move on different
asked to move head against direction when head is turned.
resistance of the examiners hands.
CN XII - The client is asked to protrude Symmetrical tongue with
Hypoglossal tongue and move it side by side. smooth outward movement
and bilateral strength

7. Diagnostic and Laboratory Procedures

Diagnostic/ Date Indication(s) Results Normal Analysis and Nursing
Laboratory Ordered/ / Purposes Values Interpretation Responsibilit
Procedures Date used in the of results ies
Result hospitals
IN
Hematology/Co Date Indications: Hemoglobi Hemoglobi Leukocytosis
mplete Blood Ordered Alter in the n: 13.0 n: 12 - 16 is present in
Count (CBC) : normal value m/cu mm m/cu mm the patient as
Decembeof the evidenced by
r 09, general Leukocyte Leukocyte the increased
2009 components Count: 11, Count: value of
of 600 m/cu 5000 – Leukocyte
Result bloodstream mm 10,000 count of
In: that mainly m/cu mm 11,600 m/cu
Decembeconsists of Hematocrit mm from a
r 10, white blood : Hematocrit normal range
2009 cells 39 m/cu : of 5000 –
(leukocytes), mm 40 - 50 10,000 m/cu
red blood m/cu mm mm. from
cells Platelets: this result, the
(erythrocytes 249, 000 Platelets: patient is
), and m/cu mm 150,000 – subjective to
platelets 500,000 further
(thrombocyt Segmenters m/cu mm infection.
es). :
80 m/cu Segmenters Segmenters
Purposes: mm : are also
To have a 55 - 70 increased as
overview of Eosiphils: m/cu mm evidenced by
the patient's 01 m/cu a value of 80
general mm Eosiphils: m/cu mm. the
health status. 2 - 4 m/cu normal value
It is also Lymphocyt mm ranges from
used to es small: 55 to 70 m/cu
indicate 19 m/cu Lymphocyt mm.
certain mm es small:
diseases that 25 – 35 Eosinopenia
is present or Erythrocyt m/cu mm is also
that have es Count: 5 evident
occurred in m/cu mm Erythrocyt because of
the patient’s es Count: the result that
body. 4.7 – 6.1 obtained 01
m/cu mm m/cu mm
from a
normal range
of 2-2 m/cu
mm.

Lymphocytpe
nia is
observably
decreased
from the test
result of the
patient.
Normal value
ranges from
25 to 35 m/cu
mm.