TABLE OF CONTENTS
I. Demographic Data………………………………………………………………………………….1
II. Reason for Seeking Health Care…………………………………………………………………1
III. History of Present Illness…………………………………………………………………………..1
IV. Past Medical
History………………………………………………………………………………...1
V. OB-Gynecological History………………………………………………………………………….1
VI. Heredo-familial History…………………………………………………………………………...1-2
VII. Developmental History……………………………………………………………………………...2
VIII.Gordon’s Functional Health Patterns…………………………………………………………..2-5
IX. Physical Examination…………………………………………………………………………….5-12
X. Diagnostic Test…………………………………………………………………………………..12-13
XI. Review of System……………………………………………………………………………………13
XII. Concept Maps………………………………………………………………………………………..13
XIII.Case Management…………………………………………………………………………………..14
A. Medical……………………………………………………………………………………………14
B. Surgical……………………………………………………………………………………………14
C. Nursing…………………………………………………………………………………………15-16
XIV. Ongoing Appraisal………………………………………………………………………………….16
I. DEMOGRAPHIC DATA
A. Initials of Clients’ Name- BBC Date of Admission:
B. Address-Bancod,Indang Cavite Time of Admission:
C. Age- 3yearsold
D. Birth Date- April 4 2016 Date of Interview:
E. Birth Place- ERS TRECE Primary Informant:
F. Gender- Male Secondary Informant:
G. Civil Status- Single Other Data Sources:
H. Religion- Christian
I. Highest Educational Attainment
J. Occupation
K. Monthly Income / Budget
II. REASON FOR SEEKING HEALTH CARE
III. HISTORY OF PRESENT ILLNESS
The client doesn’t have any present illness.
IV. PAST MEDICAL HISTORY
A. Childhood / Adult Diseases- G6Pd
B. Injuries / Accidents- The client have no history accident or injuries.
C. Hospitalization- The client haven’t been hospitalized.
D. Operation- The client have no history of operation.
E. Allergies- The client have allergy to powder and perfume.
F. Medication- The client doesn’t take any medication.
G. Immunization- The client is complete in immunization.
H. Last Examination
V. OBSTETRIC-GYNECOLOGICAL HISTORY (if applicable)
A. Menarche
B. Menstruation
- LMP
- Usual amount
- Usual Duration
- Cycle
- Associated discomforts and relief measures
C. EDC, AOG, GP-TPALM
VI. HEREDO-FAMILIAL HISTORY
A. Genogram
Paternal
CT
SideDU Maternal
DM
Side
MR
64 y/o 65 y/o 59 y/o 55 y/o
JT LB
A&W CVA CA A&W
25 y/o unknown LEGENDS: will depend on what is used.
36 y/o
NDT ET GB
5 y/o 3 y/o 8 y/o
A&W PIH COPD
A&W A&W A&W
VIII. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS
A. Health Perception – Health Management
The client doesn’t yet think how to manage his own health. It is still depend on his parents on
how his health be manage.
B. Nutritional – Metabolic
*3-day Diet Recall
MEALS Date & Day Date & Day Date & Day
Breakfast (time) MILK AND BREAD
Snacks (if any)
Lunch (time) MILK AND FEW ISCOOP OF RICE
Snacks (if any)
Dinner (time) MILK
Snacks (if any)
Total Fluid Intake ___mL ___mL ___mL
C. Elimination
The client eliminate every other day and the amount of it is minimal.
D. Activity – Exercise
The client wakes up at 7am then after he will play and uses phone. After he play the mother
of the client will bath the client.
*7-Day Activity Table
Time Days of the Week & Date
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
1 am
2 am
3 am
4 am
5 am
6 am
7 am
8 am PLAY AND PHONE
9 am TAKES A BATH
10 am
11 am
12 nn
1 pm SLEEP
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm SLEEP
10 pm
11 pm
12 mn
*Katz Index of Independence in Activities of Daily Living
Activities Independence = 1 point Dependence = 0 point
Points (1 or 0) No supervision, direction or personal With supervision, direction or
assistance needed personal assistance or total care
Bathing
Dressing
Toileting
Transferring
Continence
Feeding
TOTAL POINTS:
E. Sleep – Rest
The client sleeps in the afternoon around 1pm to 3pm and in the evening is 9pm. The client
doesn’t have any problem in sleeping.
Constructs Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Hours of Sleep
Sleeping Time
Waking Time 7am
Bedtime Rituals
Feeling upon
waking up
Problem
Encountered
F. Cognitive – Perceptual
The client doesn’t know it yet.
G. Self-Perception – Self-Concept
The client self perception is not yet known because he is still a child. The client only know is to
play.
H. Role-Relationship
The client role is to give happiness to his parents. The client is close to his parents.
*Ecomap
I. Sexuality - Reproductive
The client doesn’t sexually active yet.
J. Coping-Stress
The client doesn’t feel any stress yet because he only know is to play and have fun.
K. Value-Belief
The client doesn’t yet think about any value or belief.
IX. COMPREHENSIVE PHYSICAL EXAMINATION
A. Vital Signs Date / Time of Exam: ____________
O
T = _36_ C
PR = 110 bpm
RR = 80 cpm
BP = __/__ mmHg
B. Anthropometric Data (only those applicable)
Height = __ cm
Weight = __ Kg
Head Circumference = __ cm
Chest Circumference = __ cm
Abdominal Circumference = cm
Prepared by: Noted by:
Leah Ann Beltran, RN, MAN Nenita B. Panaligan, RN, MAN
Over-all Clinical Coordinator
Kriegel P.Bihasa, RM, RN
Reyner Joseph L. Catle, BSBio, RN Approved by:
Sunny Rose M. Ferrera, RN, MAN Lenila A. De Vera, RN, MPH, MAN
Karen Louela Rint, RN, MAN
