A. BIOGRAPHICAL INFORMATION

Name: Mckenzie Bleu L. Asuncion

Age: 10 months

Gender: Male

Religion: Pentecost

Birthdate: May 20, 2015

Birthplace: Baguio General Hospital Medical Center, Baguio City

Address: Philex Mines, Baguio City

Chief complaint: Cough, tachypnea

Diagnosis: Pediatric Community Acquired Pneumonia, Congenital Heart Disease, Patent Ductus Arteriosus

B. HEALTH HISTORY

1. HISTORY OF PRESENT ILLNESS- 1 week before admission, patient had coughing episodes, non-productive, with colds, no fever, and no

difficulty of breathing, no vomiting episodes and no change in bowel movement. 5 days before admission, patient’s condition persisted with productive cough, characterized as thick and difficult to expectorate and undocumented febrile episodes. No difficulty of breathing. Done consultation at a private clinic and prescribed with Flumucil, Salbutamol syrup and Co-amoxiclav and was sent home. Even with use of medicines, patient still had persistent productive cough. Suggested to admit at an institution where patient was diagnosed with Pediatric Community Acquired Pneumonia given with Penicillin G, Salbutamol, and Paracetamol. Few hours prior to admission, patient still not improving, transferred to Saint Louis University Hospital of the Sacred Heart.

2. PAST MEDICAL HISTORYPatient was hospitalized on 2015 due to Pediatric Community Acquired Pneumonia at Sto. Niño Hospital, Philex and discharged after 8 days with unrecalled medications. No surgical operations. No history of childhood illnesses such as chickenpox, mumps, and measles. No known allergies to foods or medications

3. HEREDOFAMILIAL HISTORYNo known history of hypertension, diabetes, heart disease, asthma, cancer, stroke, arthritis, and congenital diseases

4. SOCIAL HISTORYNo other family members have the same illness. Patient was breastfeeding. Complementary foods were introduced at 7 months. 40z per feeding for 4 to 5 times a day. Semi solid foods at 7 months

5. ENVIRONMENTPatient lives in a non-congested neighborhood in a concrete house with 5 rooms. Source of water for domestic purposes comes from the Philex water district. Drinking water comes from a mineral water refilling station. No pets. Garbage is collected every week. Toilet is indoor, flush type.

6. OBSTETRIC HISTORY The mother was 32 years old, G3P2 (2002) cognizant of pregnancy at 4 weeks AOG due to an amenorrhea from a previously regular menstrual cycle, confirmed by a pregnancy test. Prenatal checkup done at 21 weeks AOG by an obstetrician. 11 prenatal checkups done irregularly. Ultrasound done revealing a live, singleton male pregnancy. No exposures to smoking or radiation.

7. NATAL HISTORYPatient born via NSVD at Baguio General Hospital Medical Center by an obstetrician. BW: 2.8kg, APGAR and Ballard’s score is unrecalled. Pink body with good cry and active limb movements upon birth. With Down’s syndrome. Breastfed with good suck, the mother and baby stayed at the hospital for 15 days. Umbilical stump fell off after 5 days without signs of infection. Newborn screening done.

C. PHYSICAL ASSESSMENT

E. NURSING DIAGNOSIS

PROBLEMS THEORIES USED JUSTIFICATIONS1. Acute pain r/t surgical wound secondary to LSCS

This is the most prioritized problem because according to the ABC Theory, airway should be first before prioritizing others.

2. Impaired skin integrity rt surgical wound secondary to LSCS

ActualABC ( Airway, Breathing, Circulation) - BREATHING

This is the 2nd prioritized problem because according to the ABC theory, breathing comes in second when doing prioritization.

3. Risk for infection related to surgical wound secondary to LSCS

ActualOFFTERAS (Oxygen, Fluid, Food, Temperature, Excretion, Rest, Activity, Sex) - OXYGEN

This is the 3rd prioritized problem because according to Maslow’s Hierarchy of Needs, physiologic needs should satisfy first. Oxygen is the first among the OFFTERAS.

4. Risk for bleeding r/t surgical incision and postpartum complications

RiskOFFTERAS (Oxygen, Fluid, Food, Temperature, Excretion, Rest, Activity, Sex) – OXYGEN

This is the 4th prioritized problem because according to Maslow’s Hierarchy of Needs, physiologic needs should satisfy first. Oxygen is the first among the OFFTERAS. Aspiration would lead to deficient oxygen. It is also fourth because it’s only a risk and actual problems should satisfy first.

5. Risk for fluid volume deficit r/t maternal blood loss

RiskOFFTERAS (Oxygen, Fluid, Food, Temperature, Excretion, Rest, Activity, Sex) – TEMPERATURE

This is the 5ath prioritized problem because according to Maslow’s Hierarchy of Needs, physiologic needs should satisfy first. Temperature is the second among the OFFTERAS. It is also the last because it’s only a risk and actual problems should satisfy first.