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physical assessment and patient history taking, Lecture notes of Pharmacology

Angeles University (AU)Pharmacology
Prof. Ara Surat

physical assessment of the patient from the case scenario

Typology: Lecture notes

2020/2021

Uploaded on 11/15/2021

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LORMA COLLEGES CON TEMPLATE
PATIENT
HEALTH
HISTORY
RELATED LEARNING EXPERIENCE
STUDENT NAME: ESPADA, Kyla C. ROTATION: 7th rotation AREA: PEDIATRIC INTENSIVE CARE UNIT(PICU)
YR LEVEL
AND SEC: BSN 2-04 DATES: June 28, 2021
CLINICAL
INSTRUCTOR: Mrs. Editha Sabalboro
A. BIOGRAPHIC DATA
At 11:00 am, Baby girl Wency was delivered.
Weight: 2.0kg
A full blooded Filipino.
B. REASONS FOR SEEKING HEALTH CARE
NICU staffs were alerted to get ready to receive the newborn and to anticipate the need for the care of a high-risk newborn.
Baby girl Wency has small muscle mass and lack of subcutaneous fat.
Baby Wency did not cry immediately after delivery.
C. PRESENT HEALTH HISTORY
The neonate appeared pale and blueish, with weak pulses, poor perfusion with O2 Sat of 75, decreased capillary refill, and
persistent bradycardia with CR of 55.
She has also minimal response to stimuli and muscle tone, respiration is absent cold to touch with Temperature of
36 °C.
pf3

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LORMA COLLEGES CON TEMPLATE

PATIENT

HEALTH

HISTORY

RELATED LEARNING EXPERIENCE

STUDENT NAME: ESPADA, Kyla C. ROTATION: 7 th^ rotation AREA: PEDIATRIC INTENSIVE CARE UNIT(PICU) YR LEVEL AND SEC: BSN 2-04 DATES: June 28, 2021

CLINICAL

INSTRUCTOR: Mrs. Editha Sabalboro A. BIOGRAPHIC DATA

 At 11:00 am, Baby girl Wency was delivered.

 Weight: 2.0kg

 A full blooded Filipino.

B. REASONS FOR SEEKING HEALTH CARE

 NICU staffs were alerted to get ready to receive the newborn and to anticipate the need for the care of a high-risk newborn.  Baby girl Wency has small muscle mass and lack of subcutaneous fat.  Baby Wency did not cry immediately after delivery. C. PRESENT HEALTH HISTORY  The neonate appeared pale and blueish, with weak pulses, poor perfusion with O2 Sat of 75, decreased capillary refill, and persistent bradycardia with CR of 55.

 She has also minimal response to stimuli and muscle tone, respiration is absent cold to touch with Temperature of

36 °C.

 The newborn developed hypovolemic shock secondary to acute blood loss.

 APGAR score was checked which is interpreted by Nurse Guerly as “Severely Depressed”.

 At 12:00 pm, ABG result arrived with the following values: PaCO2 is 32 mmHg; pH is 7.20, and PaO2, of 70.

 The newborn weighs 2.0 kg.

D. PAST HEALTH HISTORY

E. FAMILY HEALTH HISTORY

 Her mother Sharon, a 37-year-old patient G4 P3, at 36weeks gestation she was admitted in the ER due to prolapse

of the cord. She is dilated 8 cm with obvious signs of ruptured membranes, no vaginal bleeding.

F. LIFESTYLE AND PRACTICES

1. DESCRIPTION OF TYPICAL DAY

2. NUTRITION –

3. ACTIVITY LEVEL AND EXERCISE –.

  1. SELF-CONCEPT- Patient baby Wency family are very supportive.
  2. RELATIONSHIP- Patient Wency is single.
  3. STRESS LEVEL- Having difficulty of breathing
  4. ENVIRONMENT He lives beside his family.
  5. EDUCATION AND WORK-
  6. VALUES AND BELIEFS- Patient Wency is Roman Catholic.