Modern Community Collage

Nursing Department

Data Sheet
Instructor:
Belal Abu jqem
Student Name:
Mohammad abed ikhlayel
2014


Demographic data :
- Patient initial: Mira Abu Sunaina
- Age: 7years old.
- Gender: male.
- Date of admission: 2/10/2014.
- Chief complain:
- Source of data: her Father and patient file.
- Birth date:-6/7/2007.
-
History of present illness :
Complaint patient suffering from heat, headache, lack of poise in
the movement, according to him ... He was transferred from the
outpatient clinic at the hospital and was diagnosed Pain in the
head with fever..

- Past medical history :
The patient did not suffer from any complications predecessor
-past surgical history:- no surgical in past.

-Family history:-as for the Pt family history:only the father
suffers of Diabetes maletes diseases (D/M).

Allergy: no known drug or food allergy.
Assessment:
General appearance
- Weight:29 Kg, height:130 cm.
- Body built: medium.
- Posture: erect.
- Gait: coordinated movement.
- Behavior: cooperative.

Skin:
- colour: pinkish.
- Lesions: no lesions.

Head and Neck:

Head:
Size of the head is normocephallic, circular shape, no tumors or
swelling.
Neck:
Neck size naturally, movement in all directions, thyroid gland is
symmetry, no presence of any lymph nodes.

Heart:
Resting heart rate (RHR), Systolic heart murmur.

Circulatory:
- Temperature: 37.5 C
o
.
- Pulse: 89 beats / minute.
- Blood pressure: 117/75 mmHg.
- SPO2: 92 %.

Abdomen:
- Pinkish skin color.
- Soft, flat, and symmetrical, no any tenderness , no umbilical for
hernia.

Gastro intestinal system:-
-Bowel sound:-
- Normal bowel sound.

Elimination:
- Bowel habit: stool output ranges 3 times of day.
color:- Not constant color stools, Sometimes brown.
- Urinal habit: urine output ranges between 12-15 time of day.
Frequency:- no frequency in the process of output.
The color of urine is White yellowish.
Urgency:- No urgency for urination.
Hematuria:- no blood in the urine.
Dysuria:- There's no pain during the process of urination.
No oliguria to the process of urination.

Reproductive System:

- There are no congenital malformations before birth or any malformations
after birth.

Diet and Nutrition:
Is good, and soft diet.
Muscular-Skeletal System:
- Symmetrical muscles and bone , good strength, no tenderness, no
swelling.
- No joint diseases, good extension and flexion.
- No fractures.

Neurological System:
- The patient has awareness.
- Good sensation.
-Eyes full movement in all direction.
- No paralysis.

Psychosocial :
*Good surrounding environment
* Her mother and father learners and the standard of living for
two good

Nursing care plan
Nsg
Diagnosis
Plan
Goal
Implementat
ion
Rational Evaluatio
n
Use cold
compresses
Assistance
to sleep
Increase calm.
Prevent chaos
Reduce lighting
Relaxed
patient
Stop crying
Sleeping
patient.
High
temp
Reduce
temp
Remove clothing
from the pt.
Improve air
entering the room
The level of
the
patient's
normal
temperature.
The disappear-
ance of chills.
Improve the
physical image
of the patient
General
fatigue
Remove the
fatigue.
-The seating
position is
suitable.
-Wear comfortable
clothes.
-Psychological
support from
parents.
-Provide a
comfortable
environment.
Improve self
image and
remove
fatige.
Fatigue is
remove.
Dehydratio
n
Prevent
Dehydratio
n
give IV fluid To prevent
Dehydration.
No Dehydration



Medication:
Name dose Rout Action

Side effect Indication
Ranitidine 150mg
1*2
p.o
To
preve
nt
dama
ge to
the
stoma
ch and
duode
num
for
long
time
use of
other
medic
ation.
It is used in
case of active
duodenal
ulcer, Active
benign gastric
ulcer, and in
stomach
produces acid
Headache,
Rare cases of
hypersensitivi
ty reactions
(e.g.,
bronchospas
m, fever ,
rash
contraindicat
ed for
patients
known to
have
hypersensitiv
ity to the
drug or any
of the
ingredients






(B.Aspirin)
100mg
1*1
p.o
Antico
agulan
t to
preven
t heart
attack
or any
heart
proble
ms
Secondary
prophylaxis of
myocardial
infarction,
cerebral
vascular
disease,
prevention of
occlusion after
by-pass surgery.
.
Hemorrhage,
gastritis
Any condition
a risk of
hemorrhage
such as
Pregnancy,
and ulcerative
disease.


Laboratory test :
Test performed Patient Value Normal value Comments
WBC
17.3
4.6 11k/ul
Decrease
RBC
5.15
4.1-5.5 M/ul
Decrease
PLt
241
140 450k/ul
Normal
HGB
*11.8
12-16 g/dl
Decrease
Random blood
sugar
72
0-140 mg/dl
Normal
Creatine
0.5
0.5-0.9 mg/dl
Decrease
BUN
18
7-18 mg/dL
Increase
Erythrocyte
20
0-10 mm/hr
Increase

Discharge plan

Medication
Take or administer daily, as prescribed Medication on time and regulaer
Diet
There are no forbidden foods the patient only foods that raise blood
pressure
Activity
Take a break from the physical and mental health. and more importantly
psychological support from family and relatives because they may enter into a
state of frustration or moping a result of this disease
Self care:
Attention to personal hygiene and timeliness of review when the doctor and not
neglecting any offer even if it is simple. Away from the stress and anxiety