II.

PATIENTS PROFILE

Hospital No.:

192733

Patients Name:

Ms. CB

Address:

Purok V, San Antonio II, San Pablo City,

Laguna

Gender:

Female

Birthday:

June 27, 2015

Age:

1 year old

Birthplace:

Tiaong, Quezon

Nationality:

Filipino

Civil Status:

Single

Religion:

Roman Catholic

Educational Attainment:

N/A

Occupation:

N/A

Allergies:

No unknown allergies

Admitting Time:

5:30 pm

Admitting Date:

October 27, 2016

Admitting Diagnosis:

Pneumonia, Moderate Risk

Final Diagnosis:

Pneumonia, Moderate Risk

Admitting Physician:

Lynn B. Quainzon, M.D.

Chief Complaint:

[Secondary Source] Shortness of breath,

Difficulty of Breathing, Cough & Cold

III. PATIENTS HISTORY

A. Past History
IMMUNIZATION RECORD
Immunization is recommended to protect the child from certain infectious diseases.
VACCINES
DOSE ADMINISTERED
DATE
BCG (0.5 ml: intradermal)
At birth
June 27, 2015
Pentavalent [Diphtheria,
1st dose
September 7, 2015
Pertussis, Hepatitis B,
2nd dose
October 5, 2015
rd
Haemophilus Influenzae
3 dose
November 3, 2015
type B, Tetanus] (0.5 ml:
intramuscular)
OPV (2 drops depending
1st dose
August 14, 2015
nd
on the manufacturers
2 dose
September 11, 2015
rd
institutions: oral)
3 dose
October 11, 2015
Measles with Vitamin A
9 months
March 27, 2016
(0.5 ml: subcutaneous)
It is based on the pediatric booklet of the client.

The patient is currently one year old. She is born in a health center at Tiaong,
Quezon and her mother claimed that her daughter was her 9 th child and that
her child failed to cry after the delivery and several minutes passed before she
stimulated to cry.
But after what happened, the mother perceived that her daughter was normal
like her other children after she gave birth to them.
One week prior to admission to San Pablo Colleges Medical Center, the
patient was experiencing colds then fever, and then she was sent to her
maternal parents house to take care of CB because her mother was busy
with work and her other children. The mother of the patient didnt take heed
that her mother or the grandmother of the patient has also pneumonia.
This last September 27, 2016 the patient has complaints of 1 week cough and
fever and has been hospitalized in San Pablo Colleges Medical Center in San
Pablo City, Laguna. And was diagnosed with Community Acquired Pneumonia
Moderate Risk. CB stayed for almost 7 days in the pedia ward.
CB was given Cefuroxime (Kefox) 250 mg TIV q 8, to treat severe or
complicated infections, Paracetamol 80 mg TIV q 4, to lower down
temperature, Paracetamol drops 0.8 ml q 4, to lower down temperature, for
acute cough of any etiology, Salbutamol (Ventolin) expectorant syrup 5 ml
TID, for respiratory disorders complicated by excessive secretion of tenacious
mucus, Combivent Nebulization using 1 neb BID, management of reversible
bronchospasm associated with obstructive airway diseases in patients who

require more than a single bronchodilator when she was still admitted in
SPCMC.
After 7 days, the patient requested for Home Against Medical Advice due to
lack of financial resources. The mother insisted that her child was already
cured although there were still signs and symptoms.
The patient had no known allergies in food, drugs, or medications, chemicals,
or other environmental allergens. The client has also no record for any serious
injuries and accidents.

B. Present History

Prior to admission, the patients mother verbalized that patient CB was still
experiencing fever, cough, and colds since October 4, 2016 or after
Discharging Against Medical Advice from San Pablo Colleges Medical Center,
she observed that the chest expansion has more effort, abdominal distention,
and she thinks that the patient has Difficulty of Breathing. She said that, hindi
siya makatulog tapos iyak ng iyak, tapos hindi rin siya makaiyak ng tuloy tuloy
kasi nakikita mo na nahihirapan siyang huminga at merong parang plema dun
sa dumi niya.
The mother also verbalized that she thinks patient CB acquired this illness
from her grandmother and she also thinks that infants and toddlers are prone
to acquire harmful microorganisms from environment.
Ang tagal na nung sakit niya, nakaka-ilang lingo naring nakakalipas, kasi
nung una, lagnat at sipon lang, tapos hanggang sa dalhin ko sya sa mga lola
niya, lalong lumala tapos napadala na sa ospital pagka-isang lingo, kaso
masyadong mahal doon sa ospital nay un, kaya umuwi na kami, tapos
hanggang sa nahirapan na talaga siya huminga, dinala ko nalang siya sa
District Hospital.
The mother gave ASCOF Lagundi 1/2 tsp two times a day since the illness
perceived.
Prior to admission to San Pablo District Hospital, the patient has fever, cough,
and cold since October 4, 2016 or after DAMA from SPCMC. The mother
gave Neozep Forte 2 mL for every 6 hours, practiced Tepid Sponge Bath to
lower temperature for 10-15 minutes, and applied Efficascent Oil to CBs
chest.
In the afternoon of October 10, 2016, exactly 5:30, the client was admitted in
the Pediatric Ward with Chief Complaints of Difficulty of Breathing
accompanied with Fever, Cough and Cold.
ADMISSION DIAGNOSIS: PNEUMONIA, MODERATE RISK
MANAGEMENT (hospital)
o The client has Intravenous Fluid (D 50.3NaCl) 500 mL, 35 micro drops
per minute that is run for eight hours. Intravenous fluid is necessary to
supply fluid, especially toddlers, because they tire so easily with
sucking and the patient cannot achieve a good oral intake.

o Since the client has difficulty of breathing, the doctor ordered him under
Nothing per Orem. As a relief for breathing, the patient has oxygen
inhalator via oxygen mask as needed.
o Prior to admission exactly 5:30 in the afternoon, client has temperature
of 38.7C that is why the doctor ordered Paracetamol through IV for
faster effects to the patient. The patient has prescription of several
drugs such as: Salbutamol (1 neb, q4), Ceftriaxone (200 mg, TIV,
q12), Amikacin (64 mg, IV, q12), Immunozinc drop (1.0 mL, OD),
Neozep (1 mL, q6), Cetirizine [Allerkid drops] (1.0 mL, BID), and
Forgam (200 mg, TIV, q12)
o The client also needs rest to prevent exhaustion. She needs to
conserve strength at the same time, turn and reposition her frequently
to avoid pooling of secretions.
ADMISSION Vital Signs
Temperature: 38.7C
Pulse Rate: 132 bpm
Respiratory Rate: 43 cpm
OBSERVATION
(+) crackles upon auscultation on tracheal region
(+) accessory muscles are used in breathing
(+) distended abdomen
(+) Pallor eppearance

C. Developmental Theory
SIGMUND FREUDS PSYCHOSEXUAL DEVELOPMENT
Oral Stage (0-18 months)
In the first stage of personality development the libido is centered in a baby's mouth.
It gets much satisfaction from putting all sorts of things in its mouth to satisfy the
libido, and thus its id demands. Which at this stage in life are oral, or mouth
orientated, such as sucking, biting, and breastfeeding.
Freud said oral stimulation could lead to an oral fixation in later life. We see oral
personalities all around us such as smokers, nail-biters, finger-chewers, and thumb
suckers. Oral personalities engage in such oral behaviors, particularly when under
stress.

According to clients mother, she doesnt breastfeed CB since the day she
was born. But she also said that this child is very fond of having a pacifier in
his mouth most of the time. He easily gets irritated every time his pacifier was
being removed from her. Even when she is sleeping, she will get awake and

cry when she doesnt have to suck into. Sometimes when doesnt have her
pacifier, she instead sucks her own thumb just to satisfy her oral needs.
In terms of handling different things, she always put directly in her mouth,
every object that her hands were able to grasp. That is why her parents were
trying to put all the objects which they think has the possibility to harm the
baby. All their attention and eyes were focused on their son to avoid any
unexpected accidents and also to secure the safety of the child.

ERIK ERIKSONS PSYCHOSOCIAL DEVELOPMENT

Infancy (Trust vs. Mistrust)
Existential Question: Can I Trust the World?
The first stage of Erik Erikson's theory centers around the infant's basic needs being
met by the parents and this interaction leading to trust or mistrust. Trust as defined
by Erikson is "an essential truthfulness of others as well as a fundamental sense of
one's own trustworthiness. The infant depends on the parents, especially the mother,
for sustenance and comfort. The child's relative understanding of world and society
come from the parents and their interaction with the child. A child's first trust is
always with the parent or caregiver; whomever that might be; however, even the
caregiver is secondary where as the parents are primary in the eyes of the child. If
the parents expose the child to warmth, regularity, and dependable affection, the
infant's view of the world will be one of trust. Should the parents fail to provide a
secure environment and to meet the child's basic needs; a sense of mistrust will
result. Development of mistrust can lead to feelings of frustration, suspicion,
withdrawal, and a lack of confidence.

Patient CB is much closer to her grandparents than her parents, because

most of the time she is always on her grandparents house.

She is not easy to be with, she is only comfortable with her grandparents,
sometimes with her parents. According to her mother, nako ngayon nga lang
yan sumama sakin, pero lagi parin niya hinahanap yung mga lola at lolo niya
saakin.

The mother said due to a lot of children and her work, she doesnt have the
time to spend it with all of them, while the father is also busy with his work.

JEAN PIAGETS COGNITIVE DEVELOPMENT

Sensorimotor (Secondary Circular Reaction)

Infant learns to initiate, recognize, and repeat pleasurable experiences from
environment. Memory traces are present; infant anticipates familiar events (a parent
coming near him will pick him).

They can differentiate elf from others, recognizes self as agent of action and begins
to act intentionally, and achieves object permanence. Good toy for this period: mirror;
good game; peek-a-boo.

CB likely responds to games like peek-a-boo and close-open hands.

According to her mother, when one of the family is about to carry her due to
her crying, her cry also disappears and she will be relaxed.

When she sees her grandfather and shes not in the mood, her mood will
fade away and will start playing to any member of the family.

D. Motor Development

Patient CB can get herself to a sitting position without help.

She pulls up to stand, walks holding on to furniture.
Patient can stand alone.

E. Social Development

Patient CB is shy or nervous with strangers.

The patient cries when mom or dad leaves.
CB plays games such as peek-a-boo and close-open.

F. Language Development

The patient can responds to simple spoken requests.

The patient can uses simple gestures, like shaking head no or waving byebye.
CB tries to say words you say.

G. Family History
Legend:

Deceased

Patient

Male
A&W

Alive & Well

Female
PATERNAL SIDE

MATERNAL SIDE

A&W

Heart
Attack

HTN

76 y/o

68 y/o

69 y/o

Grandfather

Grandmother

Grandfather

Pneumonia
67 y/o

Grandmother

A&W

A&W

A&W

HTN

A&W

Asthma

48 y/o

43 y/o

36 y/o

30 y/o

39 y/o

26 y/o

Daughter

Daughter

Son

Daughter

Son

Daughter

Son

Son

Daughter

Son

Son

Daughter

Son

Son

PATIENT

Narrative:
The patient has family history of Pneumonia and Asthma in the Maternal Side. And
the patient has also family history Hypertension and Heart Disease on both Paternal
and Maternal Side.

H. Hygiene
Before Hospitalization
The guardian is bathing the patient once a day in the morning. Everyday her
guardian brushes her teeth twice, in the morning and in the evening. Parents barely
wash her hands. Parents are the one who spoon feeding the patient. The parents
also barely wash hands.

During Hospitalization
The guardian provides sponge bath for the patient. The guardian provides oral care
for the patient once a day. The guardian still barely wash hands. The guardian is the
one who spoon feeding the patient.
After Hospitalization
The guardian is bathing the patient once a day. The guardian provides oral care for
the patient 2 times a day. The guardian learns from the nurse to wash hands all the
time with anti-bacterial soap.

I. Elimination
Before Hospitalization
Urination: The clients
mother estimated six to
eight times of usual
changing her childs diaper
after urination, it is not fully
loaded but of its space
are occupied. She
described it as light yellow
in color and amber urine.
Defecation: the mother
verbalized that her child
usually eliminates his stool
2-3 times a day before the
hospitalization. She
describes it as yellow in
color, slightly soft and
semi-solid in texture.
According to
Fundamentals of Nursing
7th Edition by Kozier,
characteristics of normal
infants stool is yellow in
color, formed, soft,
semisolid and moist.
Infants pass stool
frequently, often after
feeding because the
intestine is immature,
water is not well absorbed

During Hospitalization
Urination: : The clients
mother estimated 2 to 4
times of usual changing
her childs diaper after
urination, its not as damp
as the urination before her
hospitalization.

Defecation: When the

client was admitted to the
hospital during his first
day, she does not
eliminate stool. During her
second 24 hours, it is
recorded that he
eliminates her stool 2
times a day, the stool
becomes dark yellow in
color and it has evident
black pigmentation. It is
slightly moist and solid in
texture.

After Hospitalization
Urination: The clients
mother estimated six to
eight times of usual
changing her childs diaper
after urination, it is not fully
loaded but of its space
are occupied. She
described it as light yellow
in color and amber urine.
Defecation: the mother
verbalized that her child
eliminates her stool 2-3
times. She describes it as
yellow in color, slightly soft
and semi-solid in texture.

and stool is soft, liquid,

and frequent. And after
solid food are introduced,
the stool become less
frequent and firmer.
There are no evident signs
of discomforts in
eliminating stool. It is
noticeable that the patient
has no problems regarding
with his elimination before
the admission. Pero
napansin ko simula ng
magkaubo siya, may
kasama nang plema at
may bula nga, as
verbalized by the mother.
The client told that phlegm
is present in the stool
since October 7, 2016.

M. Sleep & Rest

Before Hospitalization
paputol putol ang tulog
niya, nagigising siya kasi
nahihirapan siyang
huminga, kita mo naman
yun na nahihirapan siya
tapos iiyak siya, tapos
kapag tinatanong ko kung
ano masakit, hinahawakan
niya dibdib niya as
verbalized by the mother
of the patient.

During Hospitalization
According to the mother,
patient was able to sleep
at 7:30 in the evening and
wake up at 1 in the
morning because of hot
environment that made
her uncomfortable, but
able to go back in sleep at
2:30am and wake up at 6
in the morning.

After Hospitalization
The mother said that after
the hospitalization, the
patient can sleep well
again. Approximately 7-8
hours of sleep. Because
the patient before she got
sleep, she was really a
sleepy head.