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1. PatientAssessmentDataBase:
A. General Data:
1. Patient’sName:C.S
2. Address:Pangasinan
3. Age:1
4. Sex:M
5. Birth Date:April 20, 2009
6. Rank in the family:1st
7. Nationality:Filipino
8. Civil Status:Single
9. Date of Admission:February19,2011
10. Orderof Admission:
11. AttendingPhysician:
B. Chief Complaint:LBM
C. Historyof PresentIllness: DiarheaandVomiting

2. D. Past HealthHistory/Status:
1. ChildhoodIllnesses: The patient stated that he had Fever,cough,coldsandStage 1 Dengue
2. Immunization:The patient completed his immunization
3. Major Illnesses: None
4. CurrentMedication:The patient takes paracetamol
5. Allergies:The patient stated that he has no allergy
E. FamilyAssessment:
NAME RELATION AGE SEX OCCUPATION EDUCATIONAL
ATTAINMENT
J.S Husband 26 Male OFW Under Graduate
College
G.S Wife 25 Female Housewife Under Graduate
College
C.S Son 1 Male None None

3. F. SystemReview:
1. HealthPerception –HealthManagementPattern
 Subjective:
Client’sperceptionof health: For the patient health is very important to every human being.
Client’sperceptionof illness: The patient stated that illness affects his health
Healthmaintenance andhabits: To maintain health and wellness in the family the patient emphasized the
importance of cleanliness, exercise, eating healthy and nutritious foods such as vegetables and by following the doctor’s
advice.
Compliance withprescribedmedicationandtreatment: He complies in taking her medication and treatment
prescribed by the physician.
2. Nutritional –MetabolicPattern
 Appetite:The patient has good appetite
 Food:The patient eats vegetables such as ginataang kalabasa
 Water: The patient drinks 3-5 glasses a day.
 Beverages:The patient drink’s any beverages such as juice, milk, and chocolate drinks.
3. EliminationPattern
Bowel habits:The patient defecates three times a day.
 Color:Brown
 Odor: Aromatic
 Consistency:Watery
 Laxative use:None
Bladder:The patient has no difficulty in urinating.
 Color:Yellowish
 Odor: Aromatic

4.  Alteration:None
4. Activity – Exercise Pattern
 Subjective:
Self – care ability
__Feeding __Dressing __Grooming
__Bathing __Toileting __Cooking
__Bed mobility __Home maintenance __Others
5. Cognitive –Perceptual Pattern
 Subjective:
 Hearing:Responds quickly every time we asked questions. He is not using any hearing aids.
 Vision: The patient does not use eye glasses
 Sensoryperception:Upon tapping his shoulder he responded quickly. The patient can differentiate
between sweet and bitter and can also smell the fragrance of cologne.
 Learningstyles:In order to gain information and enhance knowledge, his mother teach him on what’s
going on.
6. Sleep- RestPattern
 Subjective:
SleepHabits:The patient sleeps in afternoon and at night.
Special sleepingproblems:
Hoursof sleep:The patient sleeps 8-9 hours a day
Sleepingalterations:
Sleepingaids:The patient use sleeping aids such as watchingT.V and playinginhisbed

5. 7. Self –PerceptionandSelf –ConceptPattern
 Subjective:
Feelingaboutcurrentstate
Descriptionof self
Knowncapabilitiesandweaknesses
Self worth
8. Role RelationshipPattern
 Subjective:
Perceptionof majorrolesandresponsibilitiesinthe family
Perceptionof majorrolesandresponsibilitiesatwork
Perceptionof majorsocial rolesandresponsibilities
9. Sexuality –Reproductive pattern
10. Coping– StressTolerance Pattern
 Subjective:
Perceptionsof stressandproblemsinlife:
Copingmethodsandsupportsystemsused:
11. Value – Belief Pattern
 Subjective:
Values,goalsandphilosophical beliefs:
Religiousandspiritual beliefs:

6. G. Heredo– Familial Illness
Maternal:Diabeties,UTI, Hypertension
Paternal:Hypertension
H. Developmental History
I. Physical Assessment
A. General Survey
1. Overall appearance andgrooming
2. Actual heightandweightvs.Ideal bodyweight
3. Symptomsof distress
4. Posture gait
5. Affect,mood
6. Relevance andOrganizationof thought
B. Vital Signs
C. Regional Exam
1. Hair, headand face
Inspection:
Palpation:

7. Percussion:
Auscultation:
2. Eyes:
3. Nose:
4. Ears:
5. Mouth and Throat:
6. Neckand Lymphnodes:
7. Skin:
8. Nails:
9. Thorax and Lungs:
10. Cardiovascular:
11. Breastand Axilla:
12. Abdomen:
Inspection:
Palpation:
Percussion:
Auscultation:
13. Extremities:

8. 14. Genitals:
15. Rectumand Anus:
16. Neurological/Cranial nerves
II.Personal /Social History
A. Habits/Vices
a. Caffeine:
b. Smoking:
c. Alcohol:
d. Tea:
e.Drugs:
f.Lifestyle:
g. Social Affiliation:
h. Rankin the family:
i.Travel:
k. Educational Attainment:
III.Environmental History

9. IV. PediatricHistory
V.Introduction

10. VI. Anatomy and Physiology
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