CLINICAL APPRAISAL

A. Past Health History

Toddler X has never experience being hospitalized. He did not experience any
serious illness since he was born. Toddler X has received and completed the required
immunizations. He is not allergic to any drugs or animals. On August 2, 2010 at
exactly 10:00 pm, Toddler X was brought to the Batangas Regional Hospital due to
convulsion. His mother took care of his fever that started on July 29, 2010 and gave
him “Calpol” to reduce his fever.

B. Family History

Toddler X has five siblings. He is the youngest. He has a 19 year old sister, 18 yr.
old brother, 17 yr. old sister, 16 yr. old sister and a 13 yr. old brother. His father and
mother age is 41. Toddler X’s mother has “goiter.” His grandmother died due to
illness. There family has no history of heart disease, cancer, HPN, arthritis,
tuberculosis, etc. There family has also no history of mental illness.

C. Personal History

Toddler X sleeps once during the day. He spends his whole day playing that
sometimes he misses to sleep. He has a good eating habit. He also has a good sleeping
pattern. Toddler X has a regular elimination pattern.

D. Social History

Sometimes Toddler X is being bullied by his sibling since he is the youngest in

the family. His parents are high school undergraduate. Their family has a low
economic status. They live in a rural area that has readily available community
services specifically health centre.

E. Psychological History

Toddler X has no major stressors other than his siblings. He copes up with his
problem regarding his siblings by being comforted by his parents.

F. History of Present Illness

When Toddler X and his mother came back from Manila last July 29, 2010,
Toddler X has gained fever due to rain. Every afternoon of the next consecutive days
his fever goes up and complains for abdominal pain. On August 2, 2010 he was
brought to Batangas Provincial Hospital because he had convulsion that made his
eyes roll back in his head and loss consciousness.
S-“Kinokombulsiyon siya” as verbalized by the
mother.

O-Increase body temperature above normal range

due to convulsion.

A-Hyperthermia due to convulsion.

P-After 1 hour the client’s body temperature will

be within normal range.

I-Administered antipyretics, specifically

Paracetamol.
-Administered Diazepam to control shivering and
seizures.

E-After 1 hour of nursing intervention the client’s

body temperature is now within normal range.