I.

Patient Profile:

Name: PP
Age: 64
Address: Buag, Bambang, Nueva Vizcaya
Birthday: January 25, 1945
Status: Married
Religion: Iglesia Ni Cristo
Nationality: Filipino
Ward: Ward 2, Room 4
Admission:
Date: December 03, 2005
Time: 7:45 pm
Attending Physician: Dra. Bernedez
Admitting Diagnosis: Bronchitis
Final Diagnosis: Bronchitis

II. History of Present Illness:

The patient has chills, fever and cough prior to admission. On December 03, 2005 at
7:45pm, PP was brought to the hospital due to his complaints. The patient was diagnosed
with bronchitis.

III. History of Past Illness:

IV. Family History:

The patient has no familial diseases.

V. Brief Description of the Disease

BRONCHITIS

Definition

Bronchitis is an inflammation of the air passages between the nose and the lungs,
including the windpipe or trachea and the larger air tubes of the lung that bring air in from
the trachea (bronchi). Bronchitis can either be of brief duration (acute) or have a long course
(chronic). Acute bronchitis is usually caused by a viral infection, but can also be caused by a
bacterial infection and can heal without complications. Chronic bronchitis is a sign of
serious lung disease that be slowed but cannot be cured.

Description

Although acute and chronic bronchitis are both inflammations of the air passages, their
causes and treatments are different. Acute bronchitis is most prevalent in winter. It usually
follows a viral infection, such as cold or the flu, and can be accompanied by a secondary
bacterial infection. Acute bronchitis resolves within two weeks, although the cough may
persist longer. Acute bronchitis like any upper airway inflammatory process can increase a
person’s likelihood of developing pneumonia.

Anyone can get acute bronchitis, but infants, young children, and the elderly are likely
to get the disease because people in these age groups generally have weaker immune
systems. Smokers and people with heart or other lung diseases are also at higher risk of
developing acute bronchitis. Individuals exposed to chemical fumes or high levels of air
pollution also have a greater chance of developing acute bronchitis. Like acute bronchitis,
chronic bronchitis is an inflammation of airways accompanied by coughing and spitting up
of phlegm. In chronic bronchitis, these symptoms are present for at least three months in
each of two consecutive years.

Causes of Acute Bronchitis

 Common cold
 Flu
 Measles
 Whooping cough
 Allergies
 Smoke allergy
 Duct allergy
 Gas allergy

Symptoms of Acute Bronchitis

 Cold-like symptoms
 Painful cough
 Dry cough – dry cough in early stage
 Productive cough – usually in later stages
  Wheezing
 Throat pain
 Chest pain
 Pressure behind breastbone
 Coughing up pus in sputum
 Fever
 Generally unwell
 Trouble breathing
 Noisy breathing

Treatments for Acute Bronchitis

 Rest
 Fluids
 Pain relief
 Paracetamol
 Aspirin-but not for children
 Cough medicines
 Steam inhalation
 Heating pad
 How water bottler
 Antibiotics
 Physiotherapy
 Quit smoking
 Avoid dry foods – if milk seems to increase sputum
 Humidifier – to try to thin out sputum
 Avoid very cold weather
 Avoid very hot weather
 Oxygen
 Antibiotics
 Bronchodilators
 Steroids
 Postural drainage
VII. Laboratory Analysis

Examination Result Reference Remarks

Hemoglobin 12.8 M= 11-18 g/dl It is normal.
F= 12-18 g/dl
Hematocrit 41.2 M= 40-54 It is normal.
M= 37-47
Platelet Count 278 140-440x10 It is normal.
g/dl
WBC 17.4 4.3- It is abnormal,
10.0x10g/gl which
indicates that a
bacterial
infection is
stewing in the
body.
Granulocytes 14.1 2.0-8.8 It is abnormal,
which
indicates
infection. It
Phagocytic
activity of
Granulocyte is
increased in
anemic
persons and
those with
fever.
Lympho/Monocyte 3.3 1.2-5.3 It is normal.
Granulocyte% 81 44-80 It is normal.
Lympho/Monocyte% 19 28.0-48.0 It is normal.
Eosinophil --------------- 0-0 --------------
Bleeding Time --------------- 2.3-9.5 ---------------
Clotting Time --------------- 7-15 ---------------
VIII. Anatomy and Physiology

ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM

 The organs of the respiratory system include the nose, pharynx, larynx, trachea,
bronchi and their smaller branches and the lungs, which contain the alveoli or terminal
air sacs. Since gas exchanges with the blood happen only in the alveoli, the other
respiratory system structure are really just conducting passageways have another, very
important job. They purify, humidify, and warm incoming air. Thus, the air finally
reaching the lungs has many fewer irritants (such as dust or bacteria) than when it
entered the system, and it is warm and damp.

THE NOSE:
The only externally visible part of the respiratory system. During breathing, air enters
the nose by passing through the external nares or nostrils. The interior of the nose consists
of the nasal cavity, divided by a midline nasal septum.
 Olfactory receptors:
For the sense of smell are located in the mucosa in the slitlike superior part of
nasal cavity, just beneath the ethmoid bone.
 Respiratory Mucosa:
The rest of the mucosa lining the nasal cavity, rest on a rich network of thin-
walled veins that warms air as it flows past.

In addition, the sticky mucus produced by the mucosa’s glands moistens the air and traps
incoming bacteria and foreign debris. The ciliated cells of the nasal mucosa create a
gentle current that moves contaminated mucus posteriorly toward the throat (pharynx)
where it is swallowed and digested by stomach juices. When the external temperature is
extremely cold, the cilia become sluggish, allowing mucus to accumulate in the nasal
cavity and to dribble outward through the nostrils. This helps explain why you might have
a runny nose on a crisp, wintry day. The lateral walls of the nasal cavity are uneven owing
to three mucosa, covered projections or lobes called conchae, which greatly increase the
surface area of the mucosa exposed to the air. The conchae also increase the air
turbulence in the nasal cavity. As the air swirls through the twists and turns, inhaled
particles are deflected onto the mucus-coated surfaces, where they are trapped and
prevented from reaching the lungs.

PALPATE:
A partition that separates the nasal cavity and oral cavity, anteriorly, where the
platelets are supported but the bone is the hard palate and the unsupported posterior
part is the soft palate.
THE PHARYNX:
 Is a muscular passageway about 13 cm (5 inches) long the vaguely resembles a
short length of red garden nose.
 Commonly called the throat.
 Serves a common passageway for food and air
NARES:
Air enters the superior portion, the nasopharynx from the nasal cavity and then
descends through the oropharynx and laryngopharynx to enter the larynx below. Food
enters the mouth and travels along with air through the oropharynx and laryngopharynx.
But instead of entering the larynx, it is directed into the esophagus posteriorly.

TONSILS:
Cluster of lymphatic tissue found in the pharynx.
PHARYNGEAL TONSILS:
Often called adenoid, is located high in the nasopharynx.
PALATINE TONSILS:
In the oropharynx at the end of the soft palate.
LINGUAL TONSILS:
Are the bases of the tongue?

LARYNX:
Or voice box, routes air and food into the proper channels and plays a role in speech.
Located inferior to the pharynx, it is formed by eight rigid chyline cartilages and a spoon-
shaped flap of elastic cartilage, the epiglottis. The largest of the hyaline cartilages is the
shield-shaped thyroid cartilage, which protrudes anteriorly and is commonly called
Adam’s apple. Sometimes referred to as the guardian of the airways.

EPIGLOTTIS:
Protects the superior opening of the larynx, when we are not swallowing, the epiglottis
does not restrict the passage of air into the lower respiratory passages.

If anything other than air enters the larynx, a cough reflex is triggered to expel the
substance and prevent it from continuing into the lungs.

FUNCTIONS OF THE LARYNX:

1. PHONATION
2. PREVETION OF ASPIRATION OF FOREIGN MATERIAL
The larynx has many irritant receptors that respond by stimulating a cough
reflex.

TRACHEA:
Air entering the trachea or windpipe from the larynx travels down its length (10-12, or
about 4 inches) to the level of the 5 th thoracic vertebra, which is approximately midchest.
Lined with a ciliated mucosa, the cilia beat continuously and in a direction opposite to
that of the incoming air. They propel mucus, loaded with dust particles and other debris,
away form the lung to the throat, where it can be swallowed or spat out. The trachea is
fairly rigid because its walls are reinforced which is C-shaped rings of hyaline cartilage.
These rings serve as double purpose. The open parts of the rings about the esophagus and
allow it to expand anteriorly when we swallow a large piece of food. The solid portions
support the trachea walls and keep it patient, or open, in spite of the pressure changes
occur during breathing.

PRIMARY BRONCHI:
The right and left primary bronchi are formed by the division if the trachea. Each
primary bronchus runs obliquely before it plunges into the medial depression (hilus) of
the lungs on its own side. The right primary bronchus is wider, shorter, and straighter than
the left. Consequently it is more common site for an inhaled foreign object to become
lodged. By the time incoming air reaches the bronchi, it is warm, cleaned of most,
impurities, and well humified.

LUNGS:
Fairly large organs, Occupy the entire thoracic cavity except for the most central area,
the mediastinum, which houses the heart, the great blood vessels, bronchi, esophagus and
other organs.

APEX:
Narrow superior portion of each lung located just deep to the clavicle.
BASE:
The broad lung area resting on the diaphragm, each lung is divided into lobes by
fissures. The left lung lias two lobes, the right lung has three.
PLEURAL FLUID:
Produce by pleural membranes, slippery serous secretions which allow the lungs to
glide easily over the thorax wall during breathing movements, and causes the two plural
layers to cling together.

 Pleural secretions decrease friction during breathing. The lungs are primarily
elastic tissue, plus passageways of the respiratory tree. The smallest passageways
and in cluster of alveoli.
 The conducting zone includes all respiratory passages from the nasal cavity to the
terminal bronchioles; they conduct air to and from the lungs. Respiratory
bronchioles, alveolar ducts, and sacs and alveoli which have thin walls through
which gas exchanges are made with pulmonary capillary blood are respiratory zone
structures.

RESPIRATORY PHYSIOLOGY

PULMONARY VENTILATION:
Air must move in and out of the lungs so that gases in the air sacs (alveoli) of the
lungs are continuously changed and refreshed, commonly called BREATHING.
EXTERNAL RESPIRATION:
Gas exchange (O2 loading and CO2 unloading) between the pulmonary blood and
alveoli must take place.

RESPIRATORY GAS TRANSPORT:

Oxygen and carbon dioxide must be transported to and from the lungs and tissue cells
of the body via the bloodstream.

INTERNAL RESPIRATION:
At systemic capillaries, gas exchanges must be made between the blood and tissue
cells.

INSPIRATION:
When air is flowing into the lungs, the inspiratory muscles contract, the size of the
thoracic cavity increases. The diaphragm moves from its dome shaped to a flattened
position, increasing the super inferior volume and the external intercostals lift the rib cage
increasing the anterosuperior and lateral dimensions. Since the lungs adhere to the
thoracic walls like flypaper because of the presence of serous fluid in the pleural cavity,
the intrapulmonary volume also increase, lowering the air (gas) pressure the lungs.

EXPIRATION:
Inspiratory muscles relax and the elastic tissue recoils, both the intrathoracic and
intrapulmonary volume decrease, as the gas molecules with in the lungs are forced closer
together, intrapulmonary pressure rises above atmospheric pressure. This causes gas to
flow out of the lungs to equalize the pressure inside and outside the lungs.

GAS EXCHANGE
The requirements for gas exchange are ventilation of alveoli, perfusion of the lung,
diffusion of gases between the alveoli and capillaries, and matching of the distribution of
gas and blood in the lung.

VENTILATION:
The normal volume of gas that enters the lungs per minute is about 7.5 liter in an
adult. However, not all of that gas reaches alveoli. Some of it remains in the conducting
airways, the anatomic dead space. The amount of ventilation available for gas exchange is
about 5 L/min.

PERFUSION:
The major purpose of the pulmonary circulation is to deliver blood in a thin film to
the alveoli so that gas exchange can occur. The pulmonary vascular system high volume
low pressure system, this means that a large amount of blood flows through the lungs and
the capillary resistance to that blood flow very low.
Blood form the right ventricle of the heart is pumped into the right and left pulmonary
arteries, which branch into the alveolar capillaries. At the other alveolar capillary
membrane the blood picks up oxygen and loses carbon dioxide. After being oxygenated
the blood flows into the four pulmonary veins, which return it to the left atrium of the
heart. Under normal resting conditions only a portion of the pulmonary capillaries is
actively perfused. As cardiac output increases, pulmonary arterial pressure remains fairly
constant because of two mechanisms.
1. Recruitment of previously unperfused capillaries, which decrease pulmonary
vascular resistance and thus permits, increased blood flow through the vessels.
2. Capillary dilatation, which directly increase the capillary size and decrease the
resistance to flow. Both of these mechanisms can adjust to an increase in cardiac
output. A malfunction of these mechanisms could lead to pulmonary hypertension.
The pulmonary artery catheter is commonly used to measure the pulmonary arterial
pressure in critically ill persons. Pulmonary artery pressure may also measure
during cardiac catheterization.

DIFFUSION:
Once the air reaches the surface of the alveoli, the oxygen must cross the alveoli
capillary membrane and enter the pulmonary capillary system. Similarly, the carbon
dioxide must cross the alveolar capillary membrane to be exhaled from the lungs.
Diffusion of gases oxygen and carbon dioxide is a constant process with both gases
moving across the membrane simultaneously.
The process of diffusion depends on the thickness of the respiratory membrane, the
surface area of the membrane, the diffusion coefficients of the gases, and the partial
pressure differences of the gases being diffused. Any changes in the alveolar membrane
or the intestinal spaces between the alveoli and the capillary can affect the rate of gas
diffusion.
The process of gas exchange between the air in the alveoli and the blood in the lung
capillaries occurs because of difference in the partial pressures of the gases. Each gas
diffuses from one area of high partial pressure to an area of low partial pressure. When
the concentration of oxygen is altered, as occurs during oxygen therapy, the partial
pressures of the gases are also altered.

COMMON ALTERATIONS IN VENTILATION/PERFUSION:

MATCHING: Efficient gas exchange requires a matching of ventilation (V) and perfusion
(Q) in each alveolar capillary unit. In the normal lung, ventilation and perfusion are quite
well matched an average ventilation/perfusion ratio (Q/V) of 0.8.
When there is no more blood than air entering an area of ling, that part of the lung has
a high V/Q ratio. Dead space is the term is used to describe a lung where there is air but a
complete absence of blood. In the normal lung the airways are dead space approximately
one third of every breath is dead space. A disease state such as a pulmonary embolus,
where a pulmonary arterial vessel is blocked, also creates dead space.
Where there is less air than blood in an area of the lung, that area has a low V/Q ratio.
Because the blood does not come into contact with a ventilated alveolus, there is
decreased oxygenation of that blood. Low V/Q occurs in various diseases and is a
common cause of hypoxemia. Shunt is the term used to describe the complete absence of
air with continued perfusion. In the normal person there is a small amount of anatomic
shunt (about 2% to 5% of the cardiac output); this blood is part of the bronchial and
cardiac circulation blood that returns to the left side of the heart without “contacting” a
ventilated alveolus. Disease conditions such as congenital cardiac defects and atelectasis
can result in shunt.
The arterial blood gases (ABGs) indicate the effectiveness of the ventilation, diffusion,
and perfusion processes. Blood gas variables, especially the partial pressure of oxygen
dissolved in the arterial blood (PAO2), are influenced by elevation in comparison to sea
level. The higher the elevation, the lower is the PAO2. The normal PAO2 also decrease
with age. For example, at an elevation of 3000 feet, a normal PAO2 would be about 75 to
80 mm Hg for 40-years old man, but only about 65 to 70 mm Hg for an 80-year old man.
. COURSE IN THE WARD
February 08, 2019
8:00 am

- at 8:00 pm a 17 years old male, single with a chief complaint of dizziness,

cough, pain on both lower extremities for a few hours, fever since this morning
prior to admission.
- Vital signs were taken:
BP= 100/80 mmHg
T= 38.5°C
- He was seen and examined by ROD with orders made and carried out
- Consent signed
- Placed comfortably on bed
- With D5 0.9 Nacl inserted Skin test to Ampicillin (-) result
- CBC requested made
- Medication started

February 09,2019
12-8 pm

- With D5 0.3 Nacl ½ L at 250cc level

- Afebrile; temp = 37.4°C
- Weak as seen
- Still with cough
- Medication given
- Above IVF consumed and followed up with D5NM 1/2L
- BP 100/60

8;00am

- With D5NM ½ L at 300cc level

- Febrile throughout with temp:
10am= 39.7°C
2pm= 39.2°C

- Tepid sponge bath done

- Still with cough
- Medication given
- BP 110/90

12;00 nn
- With D5NM ½ L at 100cc level
- Highly febrile with temp:
 10am= 39.7°C
2pm= 39.2°C
6pm= 38.1°C
- Tepid sponge bath done
- IVF consumed at 5:45pm followed with D5 NM ½ L
- With on and off cough
- Medication given, more fluid intake encouraged
- BP 90/60

February 10,2019
12-8pm

- With D5 NM ½ L at 200cc level

- Febrile with temp:
2am= 39.2°C
6am= 38.1°C
- Tepid sponge bath done
- With cough
- Bp 100/70

8-4am

- With D5NM ½ L at 350cc level

- With on and off fever and cough
- Temperature were taken:
10am= 37.3
2pm= 38.2
- TSB done
- Due medication given
- Bp 110/90

4-12nn

- With D5NM ½ L at full level

- Afebrile
- Temperature taken
10pm= 36.9°C
- No complaints presented
- Medication given
- BP 100/70

X. Drug Study
 I. Doctor’s order: Paracetamol 1 amp stat if temperature is 38.5°C, Paracetamol 1
tablet every four hours.
Generic name: Acetaminophen
Brand name: Paracetamol
Classification: Non-narcotic Analgesic
Action: Decrease fever by hypothalamic effect leading to sweating
And vasodilation. Also inhibits the effect of pyrogens on
The hypothalamic heat-regulating centers. May cause
Analgesia by inhibiting CNS Prostaglandin synthesis.
Uses: 1. Control pain
2. To reduce fever in bacterial or viral infections
Contraindications: 1. Renal Insufficiency
2. Anemia
3. Clients with cardiac or pulmonary disease
Side Effects: Methamoglobinemia, Hemolytic Anemia,
Nuetropenia, Thrombocytopenia, Pancytopenia,
Leukemia

II. Doctor’s order: Salbutamol Guaifenesin 1 capsule three times a day

Generic name: Salbutamol Guaifenesin
Brand name: Ventolin
Classification: Sympathomimetic (Bronchodilator)
Action: Stimulates beta-2 receptors of the bronchi, leading to
Bronchodilation
Uses: 1. Treatment of Bronchospasm.
2. Treatment of excessive secretion of tenacious mucus.
Side effects: Tremor, changes in blood pressure, increases heart
Rate

III. Doctor’s order: Ampicillin 500 mg IVF every six hours

Generic name: Ampicillin
Brand name: Penicillin
Classification: Antibiotic
Action: Is effective against susceptible bacteria. Susceptibilities of
Bacteria to antibiotics vary from location to location. Thus,
Some doctors may use ampicillin or amoxicillin first for
Some infections.
Uses: Treatment of susceptible bacterial infections
Contraindication: Hypersensitivity
Side effects: Dermatologic: rash, allergic reaction

Anatomy and Physiology of the respiratory system

The organs of the respiratory system include the nose, pharynx, larynx, trachea, bronchi and their smaller
branches, and the lungs, which contain the alveoli, or terminal air sacs. Since gas exchanges with the
blood happen only in the alveoli, the respiratory system structures are really just conducting passageways
that allow air to reach the lungs. However, these passageways have another, very important job. They
purify, humidify, and warm incoming air. Thus, the air finally reaching the lungs has many fewer irritants
(such as dust or bacteria) than when it entered the system, and it is warm and damp.

Respiratory System

Upper Respiratory System

The Larynx
 The Bronchial tree and the Lungs

The Respiratory Bronchioles, Alveolar Ducts, and Alveoli

The major function of the respiratory system is to supply the blood with oxygen and to dispose of carbon
dioxide. To do this at least four distinct events, collectively called respiration must occur:

1. Pulmonary ventilation:
Air must move into and out of the lungs so that the gasses in the air sacs (alveoli) of
the lungs are continuously changed and refreshed. This process of pulmonary ventilation is
commonly called breathing.
2. External Respiration:
Gas exchange (oxygen loading and carbon dioxide unloading) between the pulmonary
blood and alveoli must take place.
3. Respiratory Gas Transport:
Oxygen and carbon dioxide must be transported to and from the lungs and tissue cells of
the body via the bloodstream.
4. Internal Respiration:
At systemic capillaries, gas exchanges must be made between the blood and tissue cells.

Although only the first two processes are special responsibility of the respiratory system, all four
processes are necessary for it to accomplish its goal of gas exchange.
 Respiratory Volumes and Capacities

Tidal Volume (TV):

Normal quiet breathing moves approximately 500ml of air (about to pint) into and out of lungs with
each breath.

Inspiratory Reserve Volume (IRV):

The amount of air that can be taken in forcibly over the tidal volume between 2100 and 3200ml.

Expiratory Reserve Volume (ERV):

The amount of air that can be forcibly exhaled after a tidal expiration approximately 1200ml.

Residual Volume:
Even after the most strenuous expiration, about 1200ml of air still remains in the lungs, and cannot
be voluntarily expelled.

Vital Capacity (VC):

The total amount of exchangeable air is typically around 4800ml in healthy young males.

Dead Space Volume:

Much of the air that enters the respiratory tract remains in the conducting zone passageways and
never reaches the alveoli; it amounts to about 150ml.

Gas Transport in the blood

Oxygen is transported in the blood in two ways. Most attaches to hemoglobin molecules inside the
RBCs to form oxyhemoglobin (Hbo2). A very small amount of oxygen is carried dissolved in the plasma.

Most carbon dioxide is transported in plasma as the bicarbonate ion (HCO3), which plays a very
important role in the blood buffer system. A smaller amount (between 20 and 30% of transported CO2) is
carried inside the RBCs bound to hemoglobin. Carbon dioxide can diffuse out of the blood into the
alveoli; it must be first released from its bicarbonate ion form. For this to occur, bicarbonate ions must
combine with hydrogen ions (H+) to form carbonic acid (H2CO3). Carbonic acid quickly slits to form
water and carbon dioxide, and carbon dioxide then diffuses from the blood and enters the alveoli.

Anatomy of the Respiratory Membrane (air-blood barrier)

 The respiratory membrane is composed of squamous epithelial cells of the alveoli, the
capillary endothelium, and the scant basement membranes between. Surfactant secreting
cells are also shown. Oxygen diffuses from the pulmonary blood into the alveolus.
Neighboring alveoli are connected by small pores.
(Illustration below)

Anatomy of the respiratory membrane (air-blood barrier)

VI. Physical Assessment
PSYCHOSOCIAL
Significant Others: HEALTH Occupational/Education:
HISTORY
Mother Second Year High School
Current Health Problems: Family Risk Factors:
Coping Mechanisms:
The patient feels dizzy, have cough, fever and pain on both lower General Appearance:
He talks to his mother if he feels something pain and if he can Alert,
extremities. well-built,
Habits: well nourished
The patient male, doesn’t
nor his family voice slow,
smoke skin
andcool
drink liquor.
handle it he stays at
Past Health Problems: home instead of consulting a health care and dry, black hair, thick nails and adequate capillary refill.
member.
Fever, cough, colds and anemia Health Maintenance Practices: The patient plays basketball and
Religion: Affect:
eats vegetable.
Surgical
Iglesia ni History:
Cristo Consistent in sequence of thought and design.
None
Primary Language: Orientation:
Obstetrical
Ilocano History: Medications:
He answered the question on time, date and place correctly.
Not applicable Question Answer
Name
“Anya date tatta?” Dose July 14, 2005Schedule
Accidents: Ampicillin 500mg. 9:30 itiIVF every six
“Anya oras sin?” bigat
None
“Ayan mo tatta?” Hospital hours
ANST (-)
Primary Source of Needs:
Patient Education Health Care: Memory:
Paracetamol 1 ampule Immediately
Hospital
None Immediate: We asked the patient if he still remember whatPRNhe
if temperature is
felt before he was confined. And his answer was fever, cough,
38.5 °C
dizziness and pain of both lower extremities.
Past: WeParacetamol 1 tabletsomething
ask if he can still remember Every
aboutfour
hishours
Salbutamol
immunization. And his answer1was capsule
“oo, bago ako 3 times
pumasoka daysa
Guiafenenesin
elementary”
Financial Resources Related to Illness: Speech:
Has a moderate speech.
Father – Farmer REST AND ACTIVITY
Current
Mother –Activity Level:
Housekeeper
Philhealth Nonverbal Behavior:
Activity Level Code: 0- total independence 1- assist with device 2- assist with person 3-assist with device and person 4- total dependence
He smiles and he even laugh during the interview.
Bed Mobility – 0 Chair/toilet transfer – 2 Ambulation – 0

ADLs (Activities of Daily Living)

Activity Level Code: 0- total independence 1- assist with device 2- assist with person 3-assist with device and person 4- total dependence

Feeding – 0 Bathing – 2 Dressing – 2 Grooming – 2 Toileting – 2

Sleep: The patient has complete sleep.

Body Frame, Gait, Coordination, Balance and Posture: Stands erect. Full active range of motion in all joints. Has a good posture.
Muscle:

Scale: 4- Very brisk, hyperactive; often indicative of disease; often associated with clonus (rhythmic oscillations between flexion and extension)
3- Brisker than average; possibly but not necessarily indicative of disease
2- Average, Normal
1- Somewhat diminished; low normal
0- No response

 Has a good muscle strength and tone. Rated as 2.

Motor Function:
Fine: --------
Gross
 The patient can walk and can jump.
Range of Motion:
Legs - He can extend, rotate and flex his legs
Arms - He can extend, rotate and flex his left arm but he can’t do it on his right arm because of the presence of IV.

Pain/Relief Measures:
His Mother will give him medicine whenever he feels something pain not severe and his mother will ask him to take a rest.
Mobility/Use of Device: None (He can assist himself)
SAFE ENVIRONMENT
Allergies/Reaction: None
Medications: None
Food: None
Environment: None

Eyes/Vision:
Glasses: He doesn’t wear eyeglasses
Pupils: left and right eye are reactive to light.

We examined his pupil using penlight.

 When the light is near the eye the pupil constricts and when the light is moved away from his eye his pupil dilate.

Hearing/Hearing Aid:
Hearing: We examine it by whispering the word “superman” and he repeated it correctly.
He is not wearing hearing aid.

Skin Integrity:
Lesions/Scar: The patient has no scar/lesions.
Surgical Incisions/Wounds: None

Temperature: 36 °C (Normal)

OXYGEN
Airway Clearance: There is no presence of secretion on both nose and mouth.
Respiration:
No problem on his respiratory pattern.
Respiratory Rate: 26 cycle/minute

Lung Sounds: Clear

Color:
Skin – Dark
Nails – Pinkish
Lips – Pinkish on both upper and lower lip.

Capillary Refill: 1 second

Peripheral Pulses:

Location Rate Strength Equality

Brachial Right 85 – Left 83 Strong 85-83 (unequal)
Radial Right 73 – Left 74 Strong 73-74 (unequal)
Popliteal Right 68 – Left 68 Strong 68-68 (equal)
Dorasalis Pedis Right 70 – Left 72 Weak 70-72 (unequal)

Apical Pulse: 93 beats/minute

Blood Pressure: 90/50

NUTRITION
Hospital Diet/Restrictions: Full Diet

Fluid Intake: The patient drinks 4-6 glasses of water a day.

IVs:
Site: Right side (ulna)
Solution: D5NM 1 liter at 400 cc level regulated at 43-44 micro gtts/min

Height: 2 foot 7 inches

Weight: 14 lbs.

Tissue Turgor –
We examine it by pinching the patient’s skin on his forehead.
He has normal tissue turgor since his skin moved back to normal immediately after pinching.
Ability to:
Chew – Normal
Swallow – Normal
Nausea/Vomiting – Negative
Feed self – Feeds himself

ELIMINATION
Stool: Patient has not yet defecated since he was admitted.

Urine: Patient urinate 3 to 4 times a day

Abdomen:

Bowel Sound

Lower Upper Quadrant -1 Right Upper Quadrant -2

Left Lower Quadrant -1 Right Lower Quadrant -1

Toileting Activity: Didn’t defecate yet