Nursing Assessment

A. Biographic Data

Name: Patient FJ

Age: 16 years old

Address: Mercado Hagonoy, Bulacan

Date/Place of Birth: October 11, 1994

Gender: Male

Civil Status: Single

Nationality: Filipino

Religion: Roman Catholic

Educational Attainment: Elementary graduate

Occupation: none *’di ba natin ilalagay na pahinante siya,etc? ung mga side-line nya?

Position in the Family: Eldest son

Healthcare Financing: Grandmother *db may iba pa na mas appropriate na term?  di ko lang maremember

Chef Complain: “Hindi nya maigalaw ang katawan nya” as verbalized by the client’s mother.

Admission Diagnosis: Hypokalemia Paralysis

B. Chief Complain

“Hindi nya maigalaw ang katawan ny.” as verbalized by the client’s mother.

C. History of Past Illness

 Client FJ at the age of 10 years old was accidentally hit by a stone by his friend one time on his head and got a scar on his forehead. It
eventually got healed after her auntie, a nurse, took care of his wound with Betadine. Client FJ was again hospitalized at the age of 12 due to
hepatitis A that he acquired from eating street foods but only as an out-patient. He was given medication to take at home and was advised
adequate diet by not eating junk foods and street foods to prevent acquiring the same disease again, and he was cured from it. At this moment,
he was also diagnosed with Urinary Tract Infection (UTI.)

He experienced common childhood illnesses like colds, fever diarrhea and flu. Our client remedies for these illnesses are drinking a lot
of water, taking adequate rest and acquiring over-the counter medicines like Biogesic and Neozep. The patient has no known allergies to any
foods and drugs. He doesn’t have complete vaccination; he only had BCG and OPV.

On May 2010, patient FJ was brought to at Emilio G. Perez Memorial District Hospital (EGPMDH) due to the extreme body
weakness that he was experiencing. It surprised them when he was diagnosed with Hypokalemia Paralysis. He was admitted in the hospital
for 7 days. On June of the same year, he was again hospitalized at EGPMDH with the same diagnosis having complains of general body
malaise and he lasted for 6 days on the hospital. Then, on October of the same year again, it was his third time being hospitalized at
EGPMDH with the same complaint with difficulty of breathing. He stayed on the hospital for 7 days.

D. History of Present Illness

Patient FJ was rushed at Emilio G. Perez hospital at 8 a.m of January 19, 2011 due to extreme body malaise for (1month?) with pain at
the lumbar region of his abdomen accompanied with difficulty of breathing prior to admission. He was finally admitted to the pediatric ward
of the hospital 1:00 pm of the same day. He was diagnosed with hypokalemia paralysis same as his previous medical diagnosis. The patient’s
mother states, “Hindi niya maigalaw ang katawan niya.”
 E. Family Health History

The genogram above illustrates that both his grandfathers died because of cardiovascular diseases and his grandmother on his father’s side has
arthritis. It also shows that the eldest sister of his mother died because of hypokalemia paralysis and the 5 th sibling of his mother also has the illness.
His aunt which is the 4th sibling of her mother is obese and does have cardiovascular disease. Also, the 2 nd eldest brother of his father has
 cardiovascular disease. These cardiovascular diseases are not specifically identified by his parents, and only characterized them as “sakit sa puso”
and stroke.
F. Functional Health Patterns
1. Health Perception/Health Management Pattern
Prior to Hospitalization
Our client describes his health as in a state of optimum wellness.
Whenever he is experiencing health problems such as colds, he takes a rest,
acquires over-the-counter medicines, and drinks a lot of water. He stated
that he seeks medical advice only when he acquired unusual diseases like
Hepatitis A. He does involve himself in activities or exercises like biking
and playing basketball. Aside from the said activity, our client stated that
eating a lot of foods is one of the things he does in order to keep himself
healthy. He does not engage himself in drugs and cigarettes. He has a
minimal intake of caffeine which includes colas and brown coffee.
2. Nutritional Metabolic Pattern
Prior
Client F has a typical daily food intake of rice, fish, noodles, pork and
hotdogs. He has poor appetite and usually has an irregular time on eating.
He has low tolerance on cold foods. Our client has a high intake of
carbohydrates, protein, fats and sodium. He takes multivitamins every day.
Having 65 kilogram as his weight before getting sick was his ideal body
weight. She drinks water approximately 1000ml per day. He applies green
oil on his skin. He has many lesions and dry skin and scalp. He takes a bath
twice a week, and doesn’t take a bath when he got an attack (body malaise
and difficulty of breathing) because his lola said that it might be the reason.
He had his first tooth extraction when he was 8 years old in their school.
He has tooth decay on his upper central incisors. He doesn’t have any
problems in wound healing, since they heal fast.
During Hospitalization
On our client’s hospital stay, his perception in health had changed. He
described his health as in a low state of wellness ranking it 5 out of 10 due to
his illness. He stopped drinking alcohol when he started to experience his
illness. On his own perception, he sees his illness as karma for not taking
good care of himself during his work. He said that due to forcing his body
from working, his illness becomes the effect of it. The patient cited that it
affected his work and his daily activities like biking, walking with his friend
every morning, and having difficulties caring for himself. He believes that he
acquired his illness genetically. He admits that he is having a hard time
following his treatment regimens; he still eats food that is prohibited to him
like junk foods (piattos).
During
During his stay in the hospital, client F included vegetables, fruits, meat,
Gatorade, biscuits and rice in his daily intake, which are high in fiber,
carbohydrates, proteins, and essential vitamins and minerals. He has poor
appetite and often misses his meals due to vomiting and he decided not to eat
for prevetion. He includes water (approximately 500ml/day) for her fluid
intake and gat. The doctor ordered her to have a full diet or diet as tolerated
except junk foods, carbonated drinks and caffeine. He was advised to eat
foods high in potassium like bananas, tomatoes, milk, avocados and potatoes.
The client is taking medication like __________IVF?
 72 hour diet recall

Prior to Admission During Admission

Meals Jan. 23, 2011 Jan. 24, 2011 Jan. 25, 2011 Jan. 26, 2011 Jan. 27,2011 Jan. 28,2011

-1 busog-lusog
(200 ml)
-1 glass of milk - -1 bottle of blue -1 pack magic
-3 cups sinangag
Breakfast (+) vomiting with ½ tsp. Sugar bolt Gatorade (500 flakes
8am Emergency
-1 jumbo hotdog (200 ml) ml)
room -1 glass of water
-3 glasses of water
(600 ml)

-1 medium sized
-1 pack plain sunny side up egg
-Potato Chips 35 -small fried kamote
A.M. Snack - Hansel biscuit (12 -
mg. strips (18 pcs.) -1 cup rice
pcs)
-2 glasses of water

-1 serving pancit -1 small fried

canton lumpiang toge -1 medium sized
-2 magic flakes
-2 cup rice -1/2 cup rice fried pork chop
-1 medium sized
Lunch -1 large pear -1 glass of water
-2 glasses of water -2 glasses of water banana -2 cups rice
-2 glasses of water
-3 medium sized (+) vomiting 5 -4 glasses of water
buko times
 -1 pc. Tinola
chicken thigh
-1 serving spaghetti
-1/2 large pear -3 pcs. Medium
P.M. Snack - - sliced sayote - -2 monay breads
-2 glasses of water
-1/2 cup rice -2 glasses of water

-1/2 glass of water

-1 medium sized -2 small chicken

- tortang alimasag - nuggets
Dinner - - (+) vomiting 2 (+) vomiting 2
-1/2 cup rice -2 cups rice
times times
-2 glasses of water -3 glasses of water