CASE 6 CLINICAL
A. NURSING HEALTH HISTORY
Personal Data
Name: J.C.
Age: 15 years old
Sex: Male
Race: Filipino
Religion: ,Tgie~ah Ni CrisiP
Birth Date: March 27, 1994
Birth Place: Tarlac
Present Address: Unit E-3 Bldg 10, Ilang- Ilang st. Sta. Mesa, Manila
Provincial Address: Anonas st. Panique, Tarlac
Usual Source of Health Services: UERM Medical Center
Date of Interview April 14, 2008 at 7: 00 am
Chief Complaint
"Nahihiya na ako kasi hindi pa ako tuli, takot kasi ako maoperahan", as verbalized by the
client.
History of Present Illness
1 day prior to surgery, clients parents decided to bring their child in UERMMedical Center for
circumcision JC was brought then the next day for surgery at 10 am on April 14, 2008, .
Past Medical Illness
Client claims that he has no history of hospitalization but had a chicken pox when he was 9
years old that was treated at home. His mother reported that J.C. had the following
immunization: BCGI, DPT3, HepaB3, OPV3, and MMR before he reached 10 years of age.
Family History
Client's parents denied for any hereditary disease. (Genogram not applicable)
Social History
Client J.C. is the only child in the family, living with her father and mother in Sta. Mesa, Manila. J.C.
verbalized `Hindi na magkakaanak si Mama pero ok lang kasi masaya na kaming tatlo sa bahay_'
They have an open communication with each other and with harmonious family living pattern.
They have an adequate space at 3`d floor of a condo unit type. Both his parents are
working as government employee in their City. Health Centers/ Hospitals are accessible such as
Ospital ng Sampaloc, UERM Medical Center and De Ocampo Medical Hospital.
Nutritional
Breakfast
Fried Rice
Boiled Egg
Bacon
1 cup
1 piece
3 strips
High in
Carbohydrates with
High in Protein and
Milk
1 glass
Fats
High in calcium
Fats
Snacks
Lunch
Dinner
Cake
Steamed Rice
Pork Sinigang
Steamed Rice
Chopseuy
1
1
1
1
1
slice
cup
serving
cup
serving
High in Calories
Carbohydrates
High in Protein
High in Carbohydrates
High in Vitamins and
Minerals
REVIEW OF SYSTEMS
Growth and Development
Psychosexual Theory by SIGMUND FREUD
" Client is a 19 years old male. He is on the school age in the latency stage. Psychosocial
energies are being channeled toward strong identification with one's own sex and creative
activities. Privacy and understanding one's body are important at this stage_ (Fundamentals of
Nursing by Taylor 5th Edition, page 406)
Analysis:
In relation to the patient, he is now adjusting pre-pubertal changes. His parents are supportive but
keeping their childs privacy. Client's mother verbalized °Ayaw pasabi sa kaibigan nya na nadito kami
ngayon."
Psychosocial Theory by ERIC ERICKSON
Client is in Industry-versus-Irrferirxity Stage. The school-aged child is focused on learning
useful skills and thereby developing positive setf- esteem. A sense of identity began to
emerge, and values are integrated. The emphasis is on doing, succeeding, and accomplishing(Taylor)
Analysis:
In relation to the patient, J.C. is now on the 6"' grade and has a passion on making projects
and always wanted to be on top when it comes to class performance. Client receives honors
since he entered the 1't grade up to the present according to his father.
Cognitive Theory by JEAN PIAGET
School-aged is in between Concrete to Formal Operation Phase. During concrete operation
(7-11 years old), they can solve concrete problems. They begin to understand relationships
such as size, understand left and right and they are cognizant of viewpoints. Formal
operation Phase (11-15 years old) describes that child uses rational thinking, reasoning is
deductive and futuristic. (Kozier and Erb ed pg 357, 2008)
Analysis:
Client demonstrated logical reasoning when assessed about the concepts
such as time,money and application of addition and subtraction. This implies that the client
acquires knowledge from his formal education and applies it to the real situation of life.
Moral Development by LAWRENCE KOHLBERG
Most of the middle childhood is spent in the Conventional Phase. Behavior is based on
familial and peer group beliefs, and conformity the norm is common. Following school regulations,
respecting teachers, and viewing justice as a means of fair play are all important
Analysis:
A client has no records of misbehavior on their ciass. He has also good relationship with his
fiends 'Sa bahay minsan kumakain mga classmates ko lalo na pag gumagawa kami
ng project”.
Spiritual Development by JAMES FOWLER
School-aged children view religious faith as a relationship that involves a reciprocal
fairness. They take part in rituals of their faith, with the basic understanding of the rituals
significance. The importance of spiritual beliefs and the possibility of life after death are
accepted, even if not totally understood. This stage is in Mythic-literal.
Analysis:
Client is a member of Church of Christ who attends worship service every Sunday without
fail. He is also an active officer in their church as a member of their choir. He believes that words of
God written in the bible must be obeyed in order to be saved from the Day of Judgment.
B. PHYSICAL ASSSESSMENT
(4/14/08 P.A. done before surgery)
A. GENERAL APPEARANCE
Client has a small body built with an upright posture. He is appropriately dressed. Client has neither
body odor nor bad breath odor. No obvious physical deformity. His height is 4'11' and weighs
90 lbs obtained on the day of surgery. Vital signs: T-36_5 C(axitla), RR 24cpm, PRA
10 bpm, BP-1 00/80 mm/Hg (pedia cuff used).
B. MENTAL STATUS
The client is conscious and coherent, with good affect, oriented to date, time,
person, and place. He looks nervous due to impending surgery but answers questions
appropriately.Uses simple words.
C. SKIN
The client's skin is of normal racial tone, which is brown, has warm
temperature except palm, which is cold to touch. Client's skin is smooth and has good
skin turgor. No lesions noted and hair is fine that is evenly distributed.
D. HAIR
With black hair, straight barber's cut, evenly distributed. No infection or
infestation and dandruff seen. Pubertal hair starts to grow.
E. NAILS
The client nail plate shape is concave 160. it has a smooth texture, pinkish nailbed.
Capillary refill exceeds 30 seconds. No presence of Beau’s line.
F. HEAD AND FACE
The client's skull is proporrionate to his body size and has a smooth texture.
The scalp is non tender and white. Hair is equally distributed, thin and is free from any
infestations. No presence of nodules or masses noted. The face as well as the facial
movements is symmetrical. Head has a hard consistency.
G. EYES
The client's eye condition is straight normal and eyebrows are thick. He has
equal distribution of eyelashes. The eyelids has no discharge and close symmetrically. He
has a bilateral blink response. Eyeballs are symmetric and firm. Bulbar and palpebral conjunctivas are
clear. Pupils are equally reactive to light and accomodation. Lacrimal apparatus are moist.
H. EARS
Client's auricle are of normal racial tone, whitish is brown, same with the color of the
face, symmetrical in size and position. The alignment of pinna is in line with the outer canthus of
the eye. It is elastic and nontender. Pinna recoils when folded.There's presence of some
cerumen, which is light brown in the extemal meatus. Absence of discharge and there no swelling
or redness observed.
I. NOSE
The patient's extemal nose is of normal racial tone color, brown, the same as with
the face, septum at midline, nares are symmetrical. Pink nasal mucosa, nare both patent and
nasal cavity is moist. Sinuses are nontender.
J. MOUTH AND OROPHARYNX
The patient's lips are symmetrical and dry. Buccal mucosa is dry. The tongue is at
midline, moves freely, rough and pink. Client's permanent tooth has erupted. Gums are pink, tonsils
are not inflamed.
K. NECK
The client's neck muscles are equal in size. Preauricular, pos!auricualar, cervical, and
supra davicular lymph nodes are not palpable. Trachea is at midline of neck with no deviation noted
and thyroid gland is not palpable.
L. BREAST AND AXILLA
There no masses palpated. Nipples are light brown in color, dry and
symmetrical. The axilla is color brown, dry and presence of hair starts to grow.
M. CHEST AND LUNGS
The client's chest is of normal racial tone, brown color. Lung shape is AP lateral ratio
of 1:2. Lung expansion is symmetrical anterior to posterior. Fremitus is found to be symmetrical and
decreasing in both sides. Vesicular, bronchial, and bronchovesicular breath sounds are heard. He has
a regular breathing pattern. Resonance was heard upon percussion. The costal angle of the client is
45 degrees. Aortic valve sound was heard at the 2" d right intercostals space, pulmonic valve sound
was auscultated ant 2" d left intercostals space; mitral valve was heard at the 5'' midclavicular line,
tricuspid valve sound was heard at the 4h right intercostals space. Apical pulse has a
rhythm that is regular with 80bpm; during the interview client's HR was 110 due to anxiety for the
impending surgery- No murmurs were heard.
N. HEART
The client's apical pulse is equal in rate and symmetrical with regular rhythm and
strength. HR-80 bpm, however it was only observed to be increased during the interview but it
was reassessed after 15 minutes and the result went back to 80 bpm. The apical and radial
pulse has equal rate and rhythm.
O. ABDOMEN
The client's abdomen is of normal racial tone color that is brown, flat contour and with
symmetrical abdominal movements. it has a hyperactive bowel sounds which is 25 bowel sounds
per minute, Bladder is not distended. Liver is not palpable. Upon percussion, tympany was heard.
Muscle guarding is nor present
P. UPPER EXTREMITIES
The client's motor strength is 515. he can move his extremities freely. She has no
physical deformity. Bronchial and radial pulse is present. Lymph nodes are not palpable. No
inflammation noted.
Q. LOWER EXTREMITIES
The client's motor strength is 5/5. He needs assistance in moving. Neither lesions nor physical
deformities observed. Dorsalis pedis, posterior tibial and inguinal pulses are present. Lymph nodes
are not palpable.
R. GENITALIA
Pubic hair starts to grow. There is no presence of lesions. Penis is not yet
circumcised.
S. RECTUM AND ANUS
The client's rectum and anus is patent. Gluteal folds are
symmetric. Active anal reflex.