I.

NURSING ASSESSMENT
A.Personal Data
Patients Name: Jahzeel Mary D. De Paz
Age: 6 yrs. old
Birth date: November 22, 2003
Address: Youngfield, Tacloban City
Sex: Female
Religion: Baptist
Civil Status: Single
Father: Darrius De Paz (Bombay collector
Mother: Merrian De Paz (house wife)
Diagnosis: Urinary Tract Infection
Physician: Dr. Ramas
Source of information: Mother
Reliability: 95% (reliable)

Present Illness:

Condition started 3 days prior to interview as an onset of an intermittent Fever, Dysuria

and Incontinence, used TSB as a relief for fever.

.
Past Medical History:

Patient was hospitalized at the age of 6 year old, due to Bilateral Hernia surgery last May 7, 2010 at
EVRMC. Jahzeel again has been hospitalized last june 2, 2010 at City Hospital due to UTI, associated with fever
and cough, and use amoxiclav 7ml 3x a day for 7 days, paracetamol (vial) for relief. The mother also claimed that
her daughter experienced Mumps, no treatment used. Never experience measles, chicken pox. Jahzeel is a fully
immunized child, as what the mother said.

Family History:
The mother claimed that they have heridofamilial disease, such as arthritis on the
mother side. No known genetic disease on paternal side.
Birth History:
The client is the 2nd sibling of Mr. and Mrs. De Paz, via normal delivery last November
22, 2003 at EVRMC.
Feeding History:
 The patient was breastfed from birth until 3 yrs old and 6 months. No alternative milk used. They started
supplementary feeding at an age of 7 moths, such as cerelac, smashed squash, lugaw etc. take vitamins (tiki-tiki,
celine).

Growth and Development:

Complete tooth but defective, at the age of 4 years old the client began to use toilet with assistance. Her behavior
coincides with the normal developmental theories.
Psychosocial History:

Jahzeel is a grade 1 student, with a clean classroom environment. Their house is quite messy, cemented
and has a good ventilation. No nearby lake, river, and open drainage, they use NAWASA as water supply (not for
drinking).

II. Patters of Functioning and Clinical Inspection