HEALTH MAINTENANCE AND PRACTICES

The patients mother, patient uses herbal plants such as Guyabano and he
uses it whenever experience headache and cough as verbalized by his mother. He
also takes over the counter drugs such as Alaxan and Paracetamol for headache,
bodyaches, cough and fever.

SURGICAL HISTORY

The patient has no history of surgical operation as stated by his mother.

ACCIDENTS

No history of any accidents according to his mother.

HABITS

According to the patients mother he loves to eat, watch a television and

playing toys with his cousin.

DEVELOPMENT STAGE AND TASK

On Erik Eriksons psychosocial development, the patient is under the stage of

Initiative vs. Guilt. In this stage, the child starts to develop a conscience, a sense of
mortality, and a skill of values.

The patients develop attitudes toward social groups and institutions.

PERSONS

A. PSYCHOPHYSIOLOGICAL

The patient is well-nourished. He is properly groomed and wearing the

appropriate clothes. He is a Roman catholic and his family seldom goes to
church. His primary dialect is Ilocano. Patient seldom responds with smiling
facial expression whenever student nurses talk to him.

B. ELIMINATION

Before Hospitalization During Hospitalization

Stool According to the The patients mother
mother of the stated that the
patient he usually patient usually
defecates once a defecates once a
day with a yellow day with a yellow
colored but colored semi-formed

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 sometimes varies
depending on the
food he eats. He
defecates anytime
of the day without
difficulty in
defecating
Urine According to his He voids 5 times a
mother he usually
voids 4 times a day
approximately 80-
120 ml per voiding
with clear amber
yellow. The urine
output ranges from
320-480 ml per day.
He has no difficulty
in urinating. The
patient voids
anytime of the day.
stool. He usually
defecates either
every morning or
afternoon. He
defecates easily.
day approximately
400ml
-600 ml per day with
clear yellow. The
patient voids
anytime of the day
as verbalized by his
mother.

The statement of his mother, patient never uses any laxative. He can
go to the bathroom when urinating or defecating without the help of others.
His bowel sounds are normal during auscultation with the result of 30 bowel
sounds per minute in every quadrant of his abdomen.

C. REST AND ACTIVITY

Before Hospitalization During Hospitalization

According to the patients mother he Patient still playing toys together with
loves to eat, watch a television and his brother as stated by his mother
playing toys with his cousin.

Sleep

Before Hospitalization During Hospitalization

The patient has no difficulty in going to
sleep as stated by his mother. Patient
sleeps 12 hours. He usually sleeps at 7
pm and wakes up at 7 am. Sometimes,
he takes his siesta for about 1-2 hours
between 1-4 pm during weekends.
According to his mother before the
patient undergo a surgery he sleeps 9:00
pm and usually wakes up around 7 am.
After surgery patient sleeps 8 hours a
day and he usually sleeps around 11:00
pm and wakes up at around 7 am. He
wakes up every time his vital signs are
being monitored and if its time for
administering medication.

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 D. SAFE ENVIRONMENT
The patient lives in San Antonio, Enrile Cagayan. According to his
mother, he plays toys with his cousin in their playground. His mother stated
that he has no known allergies to any environmental pollutants such as
smoke or dusts. No birthmark was noted. He has a fair skin, smooth and has
no lesions aside from his affected hand.

E. OXYGENATION

The patient has no difficulty in breathing with the Respiratory rate of 20 cpm,
where in the normal value is 15 to 25 cpm. The general skin color is brown which
is normal and has a normal capillary refill time which snaps back at 2 seconds.
The color of his lips and conjunctiva is pink which is normal. There is no noted
clubbing of nails on both upper and lower extremities.

Activity tolerance:

Before Hospitalization During Hospitalization

According to the patients mother that
he can play actively and perform some
activities such as eating, urinating and
defecating without the help of the
others.
Patient still playing toys together with
his brother. He eats his meal with the
help of the others. He needs assistance
in urinating, bathing and defecating.

F. NUTRITION
Height: 59 cm
Weight: 13KG
BMI:_______

Before Hospitalization During Hospitalization

13 kg 14

Hospital Diet/ Restrictions: The patient is on Diet as tolerated.

Fluid:

Before Hospitalization During Hospitalization

Intake According to the patients The patient consumes 1 L
mother, he can consume of water per day as stated
1.5 L per day. by his mother.
Output The mother of the patient According to the patients
stated that he voids mother, he voids
approximately 320-480 ml approximately 400-600 ml
a day per day

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 Venoclysis: The patient Intravenous fluid on his right arm, D5.3 NaCl 500 cc
x 24 hours
Ability to:

Before Hospitalization During Hospitalization

Chew The patient can chew solid The patient can still chew
foods like apple, fishes, solid foods as stated by
banana and other solid his mother.
food according to his
mother.
Swallow The patients mother The patient can still
stated that he can swallow swallow foods with no
foods with no difficulties. difficulties as verbalized
by his mother.

The patient can tolerate to eat solid foods such as fishes, banana, apple and
other solid food. He has no known food allergies. He didnt take any supplements.

Feed Self:

Before Hospitalization During Hospitalization

The patient is able to eat alone as stated According to the patients mother, he
by his mother. can eat with the help of his mother or
brother.

Usual Diet (Type)

Before Hospitalization During Hospitalization

Breakfast According to his mother, The mother stated that he
he didnt eat rice and he usually eats depending on
usually eats tinapay, the hospitals serving with
hotdog egg, vegetable like milk
sitaw (adobo) and
eggplant (fried) and fruits
like banana, apple, orange
and grapes. He drink milk
and sometimes coffee.
lunch He eats rice with fried The patient eats
chicken, fried fish and depending on hospitals
fried eggplants as serving as stated by his

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 verbalized by his mothers mother.
Dinner According to the patients According to his mother,
mother, he usually eats he eats a cup of rice with
the same serving as his vegetable and milk
lunch

Daily eating time

Before Hospitalization During Hospitalization

Breakfast They usually ate at 7:00 The patient usually eats at
am as stated by his 6:00 am according to his
mother mother.
Lunch According to his mother His meal time usually is in
they ate in between 12 between 11 am to 12
noon to 1 pm noon as verbalized by his
mother.
Dinner They took their dinner in According to his mother
between 7:00 to 8:00 pm he eats her dinner at 6:00
as stated by his mother pm

G. SPIRITUAL

According to his mother they are a Roman Catholic. His father decides for the
child with Gods guidance. His family believes in quack doctors. The parents
emphasize good manners in their child as well as the use of po and opo.

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