Mcnmcnmcn Hardcore
-
Upload
paul-loujin-lee -
Category
Documents
-
view
227 -
download
0
Transcript of Mcnmcnmcn Hardcore
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 1/26
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.
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 2/26
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
2
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 3/26
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
3
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 4/26
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
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 5/26
- 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.
5
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 6/26
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
6
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 7/26
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.
7
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 8/26
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
8
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 10/26
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)
10
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 11/26
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
11
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 12/26
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
12
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 14/26
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.
14
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 15/26
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
15
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 16/26
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
16
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 17/26
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
17
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 19/26
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
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 20/26
CAREPLAN
C. Plan of Care1. Nursing Care Plan
Cues/ Data Diagnosis Planning Implementation Evaluation
20
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 21/26
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.
21
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 24/26
PRIORITIZATION
OF PROBLEM
Prioritization of the Problems
24
8/8/2019 Mcnmcnmcn Hardcore
http://slidepdf.com/reader/full/mcnmcnmcn-hardcore 25/26
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
25