SYSTEM NORMAL ABNORMAL REMARKS

VITAL SIGNS TEMPERATURE: 36.4C The child’s vital sign are

PR= 101 within normal range
RR= 20 according to his age.
BP= 110/60
SKIN  Light brown The child has a healthy skin
 Uniform in color and has no abnormalities
 No rashses taken.
 Skin is moist
HAIR  No masses and There is no abnormal
scalp lesion findings in the hair.
 Absence of
infection
NAIL  Smooth and firm to There is no abnormal
touch findings in the nails.
 Pinkish nails
 Capilliary refill test
returns in less than
2 seconds
HEAD  No nodules and There is no abnormal
masses findings in the head.
 Asymmetrically
and round without
lesions
EYES  Eyes are There is no abnormal
symmetrical findings in the eyes.
 Eyebrows
symmetrically
aligned
 Eyes has no
discoloration
EARS  Symmetrically and There is no abnormal
color is the same as findings in the ears.
the color of the
face.
 No nodules
NOSE  Pink mucosa There is no abnormal
 No nasal discharge findings in the nose.
 No nodules and
lesion
MOUTH  Have complete There is no abnormal
teeth findings in the mouth.
 Lips is moist
 Has no nodules and
lesions
 No bad breath
CHEST AND RESPIRATORY  Breathing cycle is There is no abnormal
SYSTEM normal findings in the chest and
 No wheezes or respiratory system.
cruckles.
Patient’s Profile
Patient Charlie Canteras is a 14-year-old boy who was born March 30, 2005. He is the son of Mr. and
Mrs. Nelson Canteras and currently lives at Damurog Alcala. He is a Filipino and believes in the teaching of
Church of Christ. He was admitted at Valley Medical Center Tuguegarao last November 19,2019 and with chief
complaint of difficulty in breathing, when he experienced that pain they immediately go to CVMC.

History of Present Illness

Prior to the patient hospitalization there were no other health complaints except for his surgery in his
right upper thigh because of falling in a tree.

History of the Past Illness

According to the mother of patient Charlie the child has a full immunization. The patient doesn’t have
experienced having chicken pox, and measles.

Family Health History

The patient belongs to a healthy family. Most of her family members has no known serious illness.

Environmental History
According to the assessment of patient Charlie he has a sedentary lifestyle. His only exercise is when
he walks going to his school and going home. They’re rarely buy vegetables to eat because they plant their
own veggies in their backyard.

Interpersonal Factors
Patient Charlie spoken language is Ilocano and he doesn’t have a cultural belief that connected to his
condition now.

Current Health Information

According to the mother of patient Charlie the factors that affect his sleeping pattern is when his friends
are in their house and they sleep late. Another factor is that when he is playing on his phone until past 12
midnights.
NAME: Jhoanna Mae Romias

DATE: November 26 2019

AREA: Pedia Ward, Cagayan Valley Medical Center

CLINICAL INSTRUCTOR: Mrs. Rona Cruz

LEARNING FEEDBACK DIARY:

This was my second time exposure in hospital and render nursing care to my patient and enhance my skills in the
hospital. Our general objective is to conduct patient care as well as to gain more knowledge at the Pedia Ward. On the
other hand, my specific objective was to apply my knowledge and skills regarding nursing measures and procedures
related and needed by the patient such as getting and recording the vital signs. Though I am a bit shy to interact to the
patient I took this opportunity to challenge myself and take courage because in the near future I will be handling not one
patient but more than one.

Our clinical instructor Mrs. Cruz endorsed the patients individually and let us assess our patient one on one to
determine what is the diagnosis of the patient. I introduced myself and my purpose on my patient to gain trust and
cooperation which is not hard because he willingly to cooperate. I did my best in doing my responsibilities as a student
nurse. One thing I learned is to improve and be a competent nurse in the future. Despite the status or the disease of the
client, we as health care providers must always treat our patient equally, respect them and be able to provide health care
needs needed by the patient to alleviate their pain and cure their illness. Comparing from my duty from the surgery ward,
I had gained confidence to interact to my patient to establish rapport. I was able to get the necessary details needed for
the Vital sign record, Physical assessment and Patient’s Health History. Because my patient cooperated well, I was able
to provide a proper and accurate physical assessment for him. I am looking forward for more challenging duties and
activities in the future. And to give care to other patient.