Nursing Assignment Help - Subjective and Objective Assessment

Nursing Assignment Help Sample - Objective and Subjective Information

This paper presents the objective and subjective information of a 3-year old African American girl who is presented to the clinic by her mother with increased hunger, frequent urination especially at night, and weight loss. Besides, she gets fatigued fast and rarely completes basic activities.

Subjective Data

Chief Complaint: Increased hunger, frequent urination at night, thirst, fatigue and weight loss.  

History of Present Illness (HPI): MJ, a 3-year old African American girl, is brought to the clinic by her mother for a medical check-up. According to the mother, for the last one month, her daughter has increased hunger and thirst. Despite the mother’s increase in the quantity of food for her daughter, she has lost 2.5 pounds over the last three weeks. The mother also notes that her child has limited concentration and gets fatigued fast. At school, she has not been active for the last one month, and the teacher is concerned. She has limited activity tolerance, and the mother is in stress as the daughter cannot play anymore with other children in the neighbourhood. A critical concern is that she frequently urinates at night and has resumed wetting the bed which she stopped six months ago.  

Current Medication: MJ mother denies any medication presently. She has however been giving her daughter multivitamin as recommended by the paediatrician.  

Allergies: Mother confirms garlic allergy.

Past Medical History (PMH): MJ mother denies any serious health condition in the past besides the common cold and diarrhoea which was as a result of stomach infection.  

Past Surgical History (PSH): MJ mother denies any surgical history.

Personal/Social History: MJ’s health has deteriorated over the last one month where she has lost 2.5 pounds. However, her mother notes maintaining nutritional balance and plenty of fluid. MJ is not breastfeeding and takes multivitamin for nutritional purposes. MJ is social and active in community activities although this has reduced over the last one month.  

Immunization: MJ is current in all her immunization as demonstrated on the growth chart. Current immunization includes HepB, Hib, PCV, Tetanus, Influenza, IPV, and Chickenpox.

Family History: MJ mother notes that she is an accountant at a nearby production company while her husband is a manager at a construction firm. MJ has two other siblings who are 6 and 8 years old. All are living with MJ parents and are healthy. They are also both schooling at a nearby school. MJ mother is social and religious. They all attend Catholic and are engaged in community services. She has no health issue. The husband, on the other hand, has Diabetes Mellitus Type II which he manages using medication. Mother denies taking alcohol or any illegal drugs. Her husband, however, takes alcohol although occasionally due to his condition.

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Review of Systems (ROS)

General: MJ mother notes that in the last one month, her daughter has a number of health challenges. She has increased hunger and thirst. She is also wetting her bed, an aspect that she had stopped six months ago. She has lost 2.5 pounds over the last one month despite multivitamin and balanced food and plenty of fluids.

Skin: Mother denies any rashes or acne.

HEENT: Mother denies any hearing or visual difficulties. She denies visual blindness Mother further denies any breathing challenges. MJ is still teething although the mother denies any health condition related to this aspect. She further denies mouth sores, dental caries, or breakages. Mother also denies sore throat.  

Neck: Mother denies

Respiratory: Fast breathing and wheezing sound.

Cardiovascular: Mother denies

Gastrointestinal: Mother denies

Peripheral Vascular: Mother denies

Urinary: Mother confirms frequent urination especially at night.

Genital: Mother denies irritable bowel syndrome and constipation

Musculoskeletal: Mother confirms fatigue.

Psychiatric: Mother confirms stress due to fatigue.

Neurological: Mother denies

Hematologic: Mother denies

Endocrine: Mother denies

Objective Data

Vital Signs: Weight 30 lbs, Height 34 inches, Blood Pressure 104/76, Temperature 97.9, BMI 18.2, HR 125, RR 23, and O2 99%. The growth chart shows reduced weight.

General: MJ appears mildly sick judging from his facial expression. She is breathing normally. She demonstrates no acute distress presently. She is oriented to the environment, and there are no visual or hearing challenges. No mobility challenge noted.

Skin: No rashes or acne. Skin is smooth and intact. Skin is even in colour, and no jaundice noted.

HEENT: Head is norcephalic, appropriate in size for the patient and no indentation noted. Also, no lesions, scaling, or dryness noted. Hair is smooth. Pupils are responsive to light and equal. No injected conjunctiva noted. Eyes are bilateral. Tympanic membrane normal. No nasal congestion or difficulties in breathing. No perforation or sepal deviation. The child is still teething. No foul odour, dental caries, or teeth breakages

Neck: No LAD and neck is supple. Positive erythema. No exudate. No sore throat noted.

Lungs: No expiratory wheezes or murmurs in both lungs.

Hear/Vascular/Peripheral: S1, S2 heart sounds normal. No S3 or S4. No gallops, rubs, or murmurs. Regular heart rate and rhythm.

Abdomen: Round and soft. Palpation reveals non-tender across all the quadrants

Neurological: Patient is alert and oriented to the surrounding. She responds positively to instructions and shows no signs of acute distress. She is however sad as demonstrated in the facial expression.

Musculoskeletal: ROM positive. Gait positive and coordination is intact. There are no deformities. Strong extremities bilaterally.

Lab results.

Blood-glucose: 214 mg/dL

TC: 165 mg/dL

LDL: 98 mg/dL

A1c: 6.9%

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