Mcnmcnmcn Hardcore

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Republic of the Philippines CAVITE STATE UNIVERSITY (CvSU) DON SEVERINO DE LAS ALAS CAMPUS Indang, Cavite College of Nursing Infant Assessment Presented by: Paul Loujin L. Tabora In partial fullfillment of the requirement in NURS 50/55 for the degree Bachelor of Science in Nursing 1 University Vision The pr emier Univer si ty in hi storic Cav ite recognize d for excellence in the deve lopment of glob ally comp etit ive and moral ly upright individuals. University Mission Cavi te State Univ ersit y shal l pro vid e equ itable and releva nt educational opportuniti es in the art, scie nces and techn olog y thro ugh quality instruction and responsive resear ch and deve lo pment endeavors. It shall pr oduce prof essio nal, skil led and mora lly upri ght indi vi dual s for gl obal competitiveness.

Transcript of Mcnmcnmcn Hardcore

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Republic of the Philippines

CAVITE STATE UNIVERSITY(CvSU)

DON SEVERINO DE LAS ALAS CAMPUSIndang, Cavite

College of Nursing

Infant Assessment

Presented by:

Paul Loujin L. Tabora

In partial fullfillment of the requirement in NURS 50/55 for the degreeBachelor of Science in Nursing

1

University Vision

The premier University inhistoric Cavite recognized for excellence in the development of globally competitive and morally

upright individuals.

University Missio

Cavite State Universprovide equitable and educational opportunities isciences and technologyquality instruction and reresearch and devendeavors. It shall professional, skilled andupright individuals forcompetitiveness.

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I. DEMOGRAPHIC DATA

A. Initials of the Client’s Name – FA

B. Address – Block 26 Lot 17 R5 City homes, Dasmarinas,

Cavite

C. Age – 4 months

D. Birth Date – July 24,2010 Date of Interview: 11/24/10

E. Birth Place –Brgy. Health Center Primary Informant:

Patient

F. Gender – Male Secondary Informant: None

G. Civil Status – Single Other Data Sources:

N/A

H. Religion – Roman Catholic

I. Highest Educational Attainment – Not yet schooling

 J. Occupation – N/A

II. Reason for Seeking Health Care

Pt. FA goes to Rural Health Center with his mother for his

schedule for vaccination and for infant check up.

III. History of Present Illness

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 The patient has no history of present illness.

IV. Past Medical History

A. Childhood/Adult diseases

According to his mother he don’t have any disease when he was

born.

 

B. Injuries/Accident

According to his mother Pt. FA did not experience any accident.

C. Hospitalization

His mother said that Pt. FA did not experience to go to the

hospital.

D. Operation

Pt. FA did not undergo any operation.

E. Allergies

According to his mother Pt. FA has no known allergies.

F. Medication

Presently, Pt. FA has taking his vitamins everyday.

G. Immunization

According to his mother he have the BCG, DPT,OPV, Hepa B and

he was scheduled to go to clinic this coming december

H. Last Examination

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Patient FA’s Last examination for his Vaccination was on Nov. 17

2010.

VI. Heredo-Familial History

 A. Genogram

Paternal sideMaternal side

Legend:

4

 

MM19

FA

4mos.

JA21

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- Male

- Female

VII. Developmental HistoryTHEORIST Stage Specific Tasks Evidences of  

MilestoneAchievement

 J. Piaget’s

Cognitive

Development

“Primarycircular

reaction”

Hand-mouth andeye-earcoordinationdevelops. Infants

spends much timelooking at objectsand separating self from them.Beginning of intention of behavior is present.Enjoyable activityfor this period israttle and a tape of parent’s voice,

Pt. FA is on Sensorymotor stageparticularly “PrimaryCircular reaction”

which is 1-4 monthsold. He is on thisstage because whileI’m conducting theinterview, as Iobserved, she keepson passing her hands on her face.This only indicatesthe he is starting tolearn the hand-

mouth coordinationand soon she’ll beginto learn the ear-eyecoordinationbecause he will beable to learn thingsfrom his body.

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E. Erickson’s

Psychosocial

Development

“Trust vs.Mistrust”

Developmentaltask is to form asense of trustversus mistrust.

Child learns to loveand be loved.

The client belongs to

“Trust vs. Mistrust”

stage which means

the infant is learningto love and begins to

establish his own

self esteem as well

as his trust to others.

He is on this stage

because according

to his mother, FA

likes to interact with

others by smiling.

S. Freud’s

Psychosexua

l

Development

“Oralphase”

Child explores theworld by using themouth, especiallythe tongue.According to this

theory, infants suckfor enjoyment or torelieve tension aswell asnourishment.

Client FA is on the

“oral stage” which he

finds pleasure by

satisfying her mouth.

According to her 

mother, that he

always put to his

mouth whatever he

holds.

.

L. Kholberg’s

Moral

Development

“Prereligious

Stage”

Infants have littleconcept of anymotivating forcebeyond that of their parents.Development of trust is important inthis stage.

According toKholberg, infantsbelong to the stagecalled “Prereligiousstage” becauseinfants have littleconcept of anymotivation from their 

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parents. FA is on thisstage because hetries to develop skillsand he needsenough approval and

affection from her parents which is Mrs.MM is doing toeverything her babydo, to build theconfidence of her child.

R.

Havighurst’s

Development

Task 

“Infancyand Early

childhood”

From age 0-6 yearsold. Learning to

walk, crawl, takesolid food, to talk,to control theelimination of bodywastes. Learningsex differences andsexual modesty.Getting ready toread. Formingconcepts andlearning language

to describe socialand physicalreality.

FA belongs to stage

“Infancy and early

childhood” which she

learns new things

like to crawl, walk, sit

and other basic

movements.

VIII. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

A.HEALTH PERCEPTION-HEALTH MANAGEMENT

According to his mother she wants all for the good health

of her child.

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B.NUTRITIONAL-METABOLIC

Pt. FA currently weighed 7.4kg and stands 74cm tall. According

to his mother Pt. FA was taking vitamin C and “Tiki-tiki.

C.ELIMINATION

According to his mother Pt FA have a abnormal stool pattern. He

deficates twice a week and he have a normal amount of urine, based

on the diapers that he used in a day.

D.SLEEP-REST

Pt. FA sleeps every two hours to feed by his mother and afterthat he was going to sleep again.

IX. Physical Examination

A. Vital Signs

 T = 36.8 degree Celsius

PR =125bpm

RR =35cpm

BP =N/A

B. Anthropometric Data

Height = 74 cm

Weight =7.4 kg

C. General Appearance

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succedaneum(the fluid in acaput) isreabsorbed w/in

12 hrs or a fewdays after birth

Skin• Vernix

• Pink colour • Acrocyanosis

• Milia

Erythematoxicum• Telengiectaticnevi• Mongolianspots

• Jaundice• Cyanosis• Pallor • Petechiae• Bruising• Strawberryhemangioma• Port wine stains

Ears

-responds tosounds & voice

-normally ears areplaced with thetop of the ear (pinna) inline with inner and

outer canthi

• Normalconfiguration• Response tosound

-malformations-discharge-reddened ear -ear tags or low-seears

Eyesappearance

small conjunctival,scleral & retinal

hemorrhages arecommon

-bruised &/or puffyeyelids are normal

-erythromycin &tetracycline arenowfrequently usedprophylacticallyinstead of silver nitrate. If silver nitratedrops areused, it maycause edema &chemical

-jaundice (scleral)-opacity-anomalies; suchaseyes wide apart(spacing)

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conjunctivitiswhich mayappear a few hrsafter instillation

and disappear in1-2 days

Nose

-breathes easilythrough either nostril withlips closed-have,temporaryplugging

sneezing is anatural reflexwhich clears

nostrils

.

-obvious discharge-constant nasal

blocking

Facial skin

-smooth-pink/white milia(pinhead-sizedraised areas onnose, cheeks,forehead)

. . -refer if reddenedanditchy (eczema)-refer if suspicionof impetigo(spreading of vesicular lesion)

 

Mouth-chin is poorlydeveloped inrelation to face

-intact soft/hardpalate

Normal

configuration• Epstein’s pearl

-thrush (whitishpatches whichspread

rapidly & don’t ruboff w/o causingrednessor bleeding)

 

Neck

-contraction of theshoulder & armmuscles,followed by flexionof the neck andminimalhead lag whenpulling infant froma supineto sitting position

Normal mobility

. -more than 45degreelag-anomaly presente.g.web neck

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Hands-palmar grasp

reflex

-fingers graspadult finger when

palm isstimulated & holds

momentarily

palmar graspreflex lessens at

3-4 monthsof age

-weak or absentgrasp

Chest

-two nipples-Normal respirations(35breaths/minute)

- Normal breathsounds

-Peripheral pulses

equal to

apical

-Peripheral pulses

equal to,apical.

--may have,some

enlargement

Extra nipples• Breast abscess• Apnea• Cyanosis• Retractions• Tachypnea• Grunting• Diminished air 

entry•Crackles/wheezes• Arrythmia• Murmur • Tachycardia• Bradycardia• Peripheral pulsesdiffer 

from apical

Back-spine

. -spine straight -scoliosis

 

Abdomen

-Slight protrusion

-Normal palpation(Liver 2 cm belowcostalmargin)

• Bowel sounds

present

• Convex

• Distended

• 2 vessels

• Umbilical

inflammation,drainage

• Enlarged

o Liver

o Spleen

o Kidneys

• Bowel sound

absent

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Moro Reflex sensation of  loss of support

and is present atbirth and

disappears2-4 months

abduction of arms w/ fingersextended; then

return to

normal relaxedflexion and

closing of thefists; spine &

legs areextended with

theknees flexed; anaudible cry mayaccompany this

reflex-

disappears2-4 months

asymmetricalmovements

-if occurs after 6months may

indicateneurological

disease

REFLEXES

Reflex Mechanics Purpose Findings

 Justification

Blink Reflex

 The nurse willshine sstrong lightsuch asflashlight onotoscope

light on aneye. Andcheck if it willblink.

In order toensure theprotectionof theinfant’s eyefrom any

objectcommingnear it byrapid eyeclosure.

Present

He child have thisreflex and it will beone of thepermanent reflexof a man to protectthe eyes.

Extrusionreflex

 The nurse willplace thechild pacifier

Preventsswallowingof inedible

Present

Naturally, thisreflex diminish at 4months of life.

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in tgheanterionportion of tongue and itis expected

for the babyto extrude it.

substances.

PlantarGraspReflex

 The nurse willadminister anobject whichwill touch theinfant’s sole.If the footgraps for it, itis good.

 This is oneof thereflexesthatpreparesinfant forwalking.

Present

 This reflex diminishon 8-9 months of life. Older childrenand adults withatypicalneurology (forinstance, peoplewith cerebral Palsy

may retain these

reflexes andprimitive reflexesmay re-appear inadults because of certainneurologicalconditions.

MoroReflex

 The nurse willstarle thebaby with aloud noise,for exampleby clapping.In holdongthe baby insupineposostiontheir headswill dropbackwardaboout 1inch.

Stimulatesthe actionof someonetrying toward of attackerthencovering upto protecthimself.

Passed It is normallypresent in allinfants/newbornsup to 4 or 5months of age, andits absenceindicates aprofound disorderof the motorsystem. An absentor inadequateMoro response onone side is found ininfants withhemiplegia,brachial plexuspalsy, or afractured clavicle.

SuckingReflex

 The nurse willlightly touchthe lips of thebaby and see

 This reflexhelps thenewborn tofind food.

Present

 This reflex diminishat about 6 monthsof life. But a babywith

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if the babywill form as if he/she willsuck.

tracheoesophagealfistula willimmediatelydisappear.

Swallowi

ng Reflex

 The nurse ask

the mother if she can fedthe baby.Food raechesthe posteriorportion of thetongue isautomaticallyswallowed.

Maintain a

clearairway inthe eventthat normalswallowingdoes notkeep thepharynxfree of obstructingmucus.

Presen

t

Like the blinking

reflex, this reflex ispermanent.

Metro Manila Development Screening Test

AREA NORMALFINDING

ACTUALFINDING

 JUSTIFICATION

PersonalSocial

• Regradsface

• Smilesresponsively

• Smilesspontaneusly

Passed

Passed

Reported

• BE looks atme as Iinterview.

•  The clientsmiles backwhenever italk to her.

• As repoted

by the

mother, the

child smiles

most

especially at

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midnight.

 This is the

child's way

of 

socialization. The child

has an

increased

social

awareness.

Fine Motor • Follows tomidline

• Followspast

midline• Follows 180

degrees

• Handstogether

Passed

Passed

Passes

Reported

• When Ishow his theyarn, shefollows the

yarn to themiddle pointtogetherwith hereyes

• he alsofollowedwhen yarnpast middlepoint.

•  The childfollowed theyarntogetherwith herhead fromone side.

• According toMrs. MM,her childtouches her

fingers tomidline byherself 

Language • Respondsto bell

• Vocalizesnot crying

• Laughs

Passed

Reported

Reported

• When thechild heardthe bell, hiseyes moveas if he is

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angle fromthe table.

•  The childcannot liftup to 90

degreesfrom thetable.

•  The childholds headsteady anddropseasily.

Interpretation:FA did a good job on her overall performance on the test. Based

on different areas, she develops normal according to her age. He only

has slight delay on the Gross motor development.

NURSING19

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CAREPLAN

C. Plan of Care1. Nursing Care Plan

Cues/ Data Diagnosis Planning Implementation Evaluation

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S> pinaggagatas ko

ang anak kokasi mahinatumulo anggatas ko.

O> Bottle feedFormula Feed

.

Interruptedbreast

feedingrelated tomaternalprematurityas evidencedby low milkproduction

.

After rendering the

nursing carethe clientsmother will beable to :

>Identify anddemonstratetechniques tosustainlactation untilbreastfeeding

is reinitiated.

>Achievemutuallysatisfactoryfeedingregimen w/infant contentafter feedingand gainingweight

appropriately.

The nursewill:

>Promotesuccessfulinfant feedingby providingoptimalnutrition adnpromotecontinuationof 

breastfeedingprocess.

>Provideinformationabouteffectivebreastfeedingthroughhealthteaching and

by givingsomepamplets.

Rationale

>Providingoptimalnutritionhelps thegrowth anddevelopmentof infant.

>Educatingthe mother bygiving visualaids pampletsor anylearningmaterial willgreatly affect

theknowledge of the mother.

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PRIORITIZATION

OF PROBLEM

Prioritization of the Problems

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Risk for ConstipationCriteria Computati

onActu

alScore

 Justification

1. Nature of theproblem

3/3 x 1 1 This is considered as a riskfor the patients health

2. Modifiability 1/ 2x 2 2 The problem is partiallymodifiable since there are noresources to measure theclients problem.

3. Preventivepotential

3 / 3 x 1 1 The problem has highpreventive potential because

the problem may exist time.

4. Salience 2/2 x 1 1 The problem needs immediateattention

Total 5

Interrupted Breast FeedingCriteria Computati

onActualScore

 Justification

1. Nature of theproblem

3/3 x 1 1 The problem is consideredas actual problem

2. Modifiability 2/ 2x 2 2 The problem is easilymodifiable because the nurseresources and the clientsresources are readily available

3. Preventivepotential

3/ 3 x 1 1 The problem has highpreventive potential

4. Salience 2/2 x 1 1 The client perceives it asa problem w/c is needimmediate attention

Total 5

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