University of the East Ramon Magsaysay Memorial Medical Center COLLEGE OF NURSING Aurora Blvd.

, Quezon City GUIDE FOR THE ASSESSMENT OF NORMAL INFANT AND TODDLER Clients name: M.F Date of birth: August 7, 2008 Fathers name: K.F Occupation: Retired Mothers name: J.F Occupation: Store owner I. Birth and Maternal History 1. Antepartal: Age of mother when pregnant with this child? OB score the? Had prenatal check up? Where? Compilications during her pregnancy, if any like hypertension, edema, infections, etc.? Medications taken? 32 y/o ako nung ipinagbuntis ko siya. Hindi ko na matandaan ung OB score matagal na din kasi un, tatlong taon na din ang nakalipas. Habang ipinagbubuntis ko siya, madalas akong nagpapacheck-up para masiguradong maayos ang kanyang kalagayan. Hindi ako nagkaroon ng kahit anong komplikasyon. As verbalized by the clients mother. 2. Intrapartal: AOG? Presentation? Duration of labor? Type of delivery? Anesthesia used? Who attended the delivery? Sakto sa buwan naman siya nung ipinanganak ko siya, 38 week to be exact. Sa Hospital ko siya ipinanganak ,cesarian delivery ako. Buti nalang at may local anesthesia silang ginamit kaya nde siya masakit kahit inabot ako ng 3 oras ng labor. As verbalized by the clients mother. 3. Postpartal: Did this child cried immediately? Any cyanosis? Jaundice? Resuscitative measures done? Difficulty in feeding? Number of days in the hospital? Agad siyang umiyak ng malakas nung paglabas sa kanya. Hindi naman ako nahirapan padedehin siya. Mga isang linggo kami sa ospital nun. As verbalized by the clients mother. Age: 2 1/2 Sex: M Place of Birth: Hospital Age: 49 Age: 39

II. Physical Assessment MEASUREMENTS A. Measurement 1. Weight FINDINGS 24 lbs NORMS Weights between the 10th and 90th percentile in the standardized scale for children INTERPRETATION The clients weight is between the 10th and 90th percentile which is considered normal according to the standardized scale for children. Normal

2. Height

95cm

A child gains only about 5 in (12cm) a year. Head circumference increases only about 2cm during the second year compared to about 12cm during the first year.

3. HC

48cm

Normal

4. CC B. Vital Signs 1. Temp 2. CR 3. RR

55cm 35.9 C 125 bpm 29 bpm 36.5-37 C 80-100bpm 20-30bpm

C. Head to Toe Physical Examination BODY PARTS 1. Head FINDINGS Normocephalic, round, Head circumference: 48cm, No tenderness. Facial features are symmetric. NORMS The head must be normocephalic and round. Head circumference should correlate with the childs length. No tenderness and no irregular configurations. The hair must not have small whiteyellow, sand-szed particles attached to hair strands-the eggs(nits), pediculi INTERPRETATION The clients head is normal without any tenderness and irregular configurations. Its circumference correlates with her length.

2. Hair

Black in color, evenly distributed, shiny, strong. Clean scalp

The clients hair is normal.

(head lice). Evenly distributed, shiny, strong and good body. 3. Eyes Symmetrical, sclera is white, conjunctiva is moist and pink, good eyesight. No edema and redness noted. Pupils constrict when light is introduced. The location of the eye in relation to the nose is equally spaced. Lids and lashes must not be inflamed. No discharges. No tenseness in each eye globe while the eyelids are closed. Mucous membrane is pink and moist. Pupils constrict in response to light, an indication that the 3rd cranial nerve is intact. Properly aligned Symmetrical. The inner canthus of the eye to the outer canthus and then to the ear will touch the top of the pinna of the ear. No discharge in the ear canal. No pain on the pinna of the ear. The ear lobes are not inflamed and there are no drainages from infected pierced earring sites. The color of the membrane is pinkish gray. In the midline. No flaring of nostrils. Mucous membrane of the nose is pink. No discharges. Septum is in the midline. Both sides of the nose are patent. Symmetrical lips. 20 The clients eyes are normal.

4. Ears

Symmetrical, auricle aligned with the outer canthus of the eye, not tender, pearly gray tympanic membrane. Presence of some wax (cerumen).

The clients ears are normal. Although it has earwax in the ear canals, appearing as dark-brown, the tympanic membrane can be viewed using the otoscope, however, it must be eliminated so it will not impair the hearing capability of the client.

5. Nose

Aligned at the center of the face. straight, no discharge, not tender, uniform color, Air moves freely as the clients breathes through the nares Lips are symmetrical

The clients nose is normal.

6. Mouth

The clients mouth is

and red in color. Oral mucosa is moist and pink. The tongue is smooth and moist. Uvula is at the center. No cavities in teeth. No swollen or inflamed gums.

shiny and white toddler teeth. No cavities in teeth. Facial muscles are symmetrical. Oral mucosa is moist and pink. Tongue is smooth and moist, in the midline position, not tender and no fasciculations. NO lesions. No swollen or inflamed gums. Uvula is in the midline. Symmetrical. The trachea is in the midline. Normal contour of the thyroid gland. No pain on moving the head in different directions.

normal.

7. Neck

Symmetrical. No lesions, tenderness and swelling noted. Skin is intact.

The clients neck is normal. Any deviation suggests lung pathology. And because children have so many upper respiratory infections, a few nodes about a size of a pea are often present The clients skin is in good condition however, in this age they have minor lesions from mosquito bites. They also have some ecchymotic spots on the lower extremities from bumping into objects during active play. The clients Respiratory rate is within the normal range. There are also hyperresonant sounds upon percussion of the lungs due to the thinness of the chest wall.

8. Skin

Smooth, uniform color, good skin turgor, warm to touch, presence of minor lesions from mosquito bites.

Smooth, uniform color, good skin turgor, warm to touch. Presence of minor lesions from mosquito bites. Presence of ecchymotic spots on the lower extremities RR: 20-30 bpm. No DOB. Hyperresonant sounds upon percussion of the lungs. Lungs filled with fluid sound less resonant. Lower anterior lobe of the right lung is dull because the liver covers it. Normal breath sounds. HR: 80-100 bpm The point of

9. Lungs

RR: 29 bpm No difficulty of breathing. Hyperresonant sounds upon percussion of the lungs. Dull sounds over the liver. Normal breath sounds.

10. Heart

HR: 125 bpm. Visible pulsations on the

The clients heart rate is beyond the normal

mitral area. Dull sound over the heart. Normal heart sounds. Regular rhythm and intervals.

maximum impluse is observable. Dull sound produced upon percussion over the heart. Normal heart sounds upon auscultation. Regular rhythm and intervals. Symmetrical surface and contours. No tenderness. Unblemished skin, uniform color, warm to touch, pouchy. Normal bowel sounds. Palpable organs. Normal muscle mass and circumference, normal strength and mobility, no edema and tenderness, normal reflexes, decreasing amount of fats on the legs No free edges, smooth, pink, not cracked, convex

range because she has a fear with medical personnel after having a trauma from her last medical check-up because of the different test utilized to her. The clients abdomen is normal. It appears pouc hy because at this age their abdominal muscles are not yet fully developed.

11. Abdomen

Unblemished skin, uniform color, warm to touch, pouchy. Normal bowel sounds.

12. Extremeties

Normal muscle mass and circumference, normal strength and mobility, no edema and tenderness, normal reflexes, decreasing amount of fats on the legs No free edges, smoothn, pink, not cracked. 10 fingernails and 10 toe nails. No diarrhea or constipation noted No tenderness and swelling noted. No discharge and irritation

The clients upper and lower extremities are proportional with each other.

13. Finger and toenails

The clients Finger and toenails are all normal.

14. Gastrointestinal

No diarrhea or constipation noted No contours. No discharges. No pain and irritation. No bulging of the groin area.

The clients gastrointestinal tract is normal The clients Genitorectal tract is normal.

15. Genitorectal

D.

Motor Development FINE/ GROSS MOTOR SKILLS 1. Can open doors by ABLE TO PERFORM YES NO The client was able to INTERPRETATION OF FINDINGS

turning doorknobs, unscrew lids 2. Makes simple lines or strokes for crosses with a pencil 3. Walks alone well without assistance 4. Can seat self in chair 5. Can run and jump in places 6.Can jump down from chair 7. Can dance simple steps 8. Can stack up 9 blocks

YES

YES

perform the enumerated fine/gross motor skills without having any difficulty and without any assistance.

YES YES YES YES YES YES

E.

Neurological Assessment REFLEXES Biceps Reflex HOW ELICITED Flex the clients arm at the elbow, and rest the forearm over the thighs, placing the palm of the hand down. Place the thumb of the non dominant hand horizontally over the bicep tendons. Deliv er a blow with the percussion hammer to the FINDINGS +2 Normal Response NORMS Scale grading Reflex responses: 0 No reflex response +1 Minimal activity +2 Normal response +3 More active than Normal INTERPRETATION The client has a normal automatic response of the body stimulus.

thumb. obser ve Triceps Reflex Flex the clients arm at the elbow, and support it in the palm of your nondominant hand. Palpa te the triceps tendon about 2-5 cm above the elbow Deliv er a blow with the percussion hammer directly to the tendon Obser ve Patellar Reflex Ask the client to sit on the edge of the table so that the legs hang freely Locat e the patellar tendon directly below the patella Deliv er a blow with percussion hammer directly to the tendon Obser ve

+4 Maximal activity

 F.Activities of Daily Living 1. Nutritional Pattern -Breastfeeding: frequency, duration, reaction to breastfeeding? -Formula feeding: brand of milk, quantity per feeding, dilution, number of feedings per day, schedule, change in formula, why?, age weaned (if applicable) -Supplementary feeding: age when first given solid foods, first solid food given, solid foods take at present, how often? -Foods likes and dislikes -How is her appetite? -Presence of any food allergy. Na-breastfed ko siya hanggang 1 taon siya at pagtapos nun bingyan ko na siya ng powdered milk, ung Anchor. Madalas ay nakaka-apat na bote siya ng gatas sa isang araw. Nung 1 y/o din siya. Binigyan ko na din siya ng mga solid food katulad ng kanin na may sabaw minsan naman ay tinapay o kaya naman biscuit, ung Marie. At ngaun naman ay nagkakakain na din siya ng mga sitsirya, mga candy at iba pang matatamis. Hindi naman namin siya mapigilan sa pagkain nito kasi umiiyak siya kapag nde naibibigay ang gusto niyang kainin. Wala naman siyang allergy sa kahit anong pagkain. As verbalized by the clients mother. Analysis: Nutrition Imbalanced: less than body requirement r/t knowledge deficit. 2. Rest and Sleep -How long does he sleep at night? During the day? -How do you put her to sleep? -How does she wake up? Madalas mga 10 oras ang tulog niya, 8 oras magmula gabi hanggang umaga na yon tapos mga 2 hanggang 3 oras naman siyang natutulog tuwing hapon. Para naman makatulog siya kailangan talaga ay tahimik ung paligid at paminsan naman ay kinakarga ko siya hinehele ko para lang makatulog siya. Kadalasan naman sariling gising siya o kaya naman kapag nagugutom na siya at gusto na ng dede. As verbalized by the clients mother. Analysis: Readiness for enhanced Sleep-Rest pattern 3. Personal Hygiene -Is the child bathed? How often? -Is oral care provided? How? How often? -Does the child look neat and clean? Properly dressed? -Any problem related to hygiene

Araw-araw naman siyang pinapaliguan kung minsan 2 beses kasi bata madalas kung saan nagsususuot kaya nadudumihan kaagad at dahil na rin sa sobrang int ng panhon ngayon. Alam na din niya ung kung paano ang tamang pagsipilyo 2 hanggang 3 beses sa isang araw. Sinisigurado ko din na malinis at komportableng mga damit na ipinapasuot ko sa kanya. As verbalized ny the clients mother. Analysis: Readiness for enhanced good personal hygiene 4. Elimination Pattern -Bowel consistency, color, odor, frequency, control -Bladder: frequency, color. control -Elimination problem encountered by parents? How managed? Mga 4 hanggang 5 beses siya umiihi sa isang araw at mga 1 hanggang 2 beses ang kanyang pagdumi. Madilaw ang kanyang ihi at kulay brown at malambot naman ang kanyang tae. At ayon sa obserbasyon ko sa kanya, hindi naman siya nahihirapan gawin ang mga ito. As verbalized by the clients mother. Analysis: Readines for enhanced elimination pattern 5. Health Supervision -Is the baby brought regularly to the well-baby clinic? -How is health of the baby maintained? Pinapacheck up namin siya sa health center, lalo na kapag masama ang pakiramdam niya, kaso lang nahihirapan kaming dalhin siya doon kasi natatakot na siya sa mga doctor, nurse. Nung last january kasi, nung nagkasakit siya natrauma siya sa mga injection at sa mga pinaggagawa ng mga doctor sa kanya. Pinapainom naman namin siya ng mga gamot na meron kami dito sa bahay katulad kapag may simpleng ubo at sipon lang siya . As verbalized by the clients mother Analysis: Moderate Anxiety related to health interaction. III. Emotional Assessment 1. Can you meet readily the needs of your baby? Oo! Nung pinanganak naman sya, pinabakunahan na naming sya. Sa ospital kasi sya pinanganak. Lumaki naman sya ng maayos, at nakakakain ng tama sa oras Do you have schedule of your babys daily activities? Oo naman! Lalo na nung baby pa sya, nung pagkapanganak. Kasi kailangan talagang mabantayan. Pero pag may pasok ako, yung dalawang kapatid nya ang kalaro nya Does your baby sleep soundly? Hindi naman Tuloy tuloy naman tulog niya pag gabi.. di naman siya biglang gigising tapos iiyak, pero nung nagkasakit siya last January 2009, oo dahil di siya kompartable, at masama ang pakiramdam Do you always talk to your baby?

2.

3.

4.

Oo, lalo na ngayong 3 years old, syempre madaldal na, pero kahit nungwala pang 1 year old, kasi nakakaintindi naman siya 5. Do you always kiss, hug and touch him/her? Oo, bago matulog, bago pumasok sa trabaho, pag naglalambing, pag naglalaro. When your baby cries, do you go to him right away? How do you pacify him? Oo, pinupuntahan ko siya agad, tinignan ko muna kung anong nangyari, tapos pinapatahan ko, para alam ko kung ano dapat gawin. Baka kasi naumpog, o nadapa mahirap na. Pero pag gutom o biglang nagising, binigyan ko agad ng gatas Do you wake up at night to check your baby? Oo, katabi ko naman sila pag natutulog Who takes care of your baby most of the time? Sa ngaun madalas yung ate (eldest) nya, pero lahat naman kami inaalagaan siya How many hours do you allot for taking care of your baby? Di naman na sya alagain sa ngaun, pero pag naglalaro sya, minsan hinahayaan lang, pero may nakabantay sa kanyaPero siguro mga 8 oras o mahigit Do you encourage/ allow him to sit up, stand up, walk and do other activities? Oo naman pinapayagan ko kasi parte naman yun ng paglaki, Noon mga 8 months pa lang ata sya kaya nya na maglakad, tumayo How does your baby react when you give attention to other children? Minsan nagseselos, umiiyak, nagagalit How does your baby behave when you leave the house without him? Nung una talaga sobra umiiyak siya, buti na lang nandyan yung ate nya para magbantay sa kanila Pero ngayon parang nasanay na, .. alam niya kasing may trabaho ako, at alam niya naman na babalik naman ako sa hapon, pero siyempre medyo nalulungkot siya kaya nilalaro laro siya para din a umiyak How does he react when he is being teased? Nagagalit sa akin, tapos di ako pinapansin, pero saglit lang madali naman kasing makipagbati madali niyang kalimutan na galit siya.. What does he do when he wants to be carried but you did not carry him? Nagagalit siya tapos umiiyak, pero pag tumagal na, tumitigil na siya mas gusto niya na kasi ngaun maglaro What does he usually do if his wants are not satisfied? Umiiyak siya

6.

7. 8.

9.

10.

11. 12.

13.

14.

15.

16. How does he react to people he does not know? Does he cry when carried by a stranger and stop when you get him? Umiiyak siya pag binuhat siya ng di niya kilala, nangingilala kasi. Pero pag kinuha ko na tumatahan naman na siya

17.

Do you allow him to play while being bathe? Oo Mild Anxiety Related to Separation

Analysis:

IV. Psychological Living 1. 2. 3. 4. What does he usually do with anything that he holds? nilalaro niya dati sinusubo niya, pero ngaun, medyo hindi na Does your baby always salivate? di naman na Do you give him pacifier? How often or how long is this given? dati nung mga 1 year old sya.. Does he put his finger? Toe nails in his mouth? hindi Analysis: Readiness for enhanced self care

V. Cognitive Development 1. How does your child react to songs? Nursery rhymes? Stories? Pag naririnig niya yung kanta, sinasabayan niya, lalo na sa pinapanuod naming, may part sa song, na medyo saulo niya na.. How does he react to new object that he sees? tinitignan niya, lalo na pag mukhang maganda para sa kanya, tapos pag di niya nagustuhan, ayon nilalapag niya na lang How does he react when an object is taken away from him? umiiyak siya, nagagalit lalo na pag yung kinuha mo , nilalaro niya pa, or kung yon yung favorite niyang laruan Readiness for enhanced cognitive development

2.

3.

Analysis:

VI. Social Development 1. 2. What toys do you give your baby? barbie, doll house, minsan siya na namimili kung anu lalaruin niya What is his favorite toy?

 gusting-gusto niya ng doll house, mga Barbie, at lutu-lutuan 3. How does he react when you play with him? may time na nakikipaglaro siya sa akin, may time ayaw niya.. nagagalit.. How often does he play daily? madalas siyang naglalaro, sa umaga, naglalaro na siya, pati sa hapon Readiness for enhanced social development

4.

Analysis:

VII. Body Image Development 1. 2. 3. How often do you caress your baby? Madalas, gusto ko lagi silang malinis, para iwas sakit na rin Can he already point to his nose, mouth and other parts of the body? Oo, alam niya naman na yung ibang part ng katawan How does he react when he sees himself in the mirror? tuwang- tuwa siya..mahilig kasing magpapicture kaya pati sa salamin ng popose.. :) How often does your baby play with parts of his body? minsan siya na ang kusang nag-iipit sa buhok niya, kahit magulo.. kasi di pa naman niya kayang ipitan ng maayos How often does he play? Minsan lang How do you keep him clean? Pagkatapos maglaro, pinapalitan na siya ng damit, basta pag nadumihan minsan siya nagsasabi na palitan siya ng damit, ayaw niya rin kasi ng madumi siya, lalo na pag mainit How do you scold him if he gets dirty? How does he react? di ko naman siya pinapagalitan agad pag nadumihan siya, pinagsasabihan ko muna, pero pag-naulit ulit, ayon medyo nagagalit na ako, pinapalo ko na siya, para alam niya na di maganda iyon nakikinig naman siya sa akin pag pinagsasabihan ko Do you kiss/ praise him lovingly? How often do you do this? Oo, lagi ko siya hinahalikan, tapos pinapakita ko na natutuwa ako sa mga ginagawa nya, basta nasa tama

4.

5. 6.

7.

8.

9. Do you give him the opportunity to learn the difference of his body from the other things in the environment? Give examples. Oo, minsan. Tulad pag nakikita niya sa tv, yung mga pwede gawing example doon..

Analysis:

Readiness for enhanced self concept

VIII. Speech and Language Development 1. 2. 3. Can your baby talk already? Oo When did he first talk? mga 10 or 11 months nakakapag salita na siya.... How often do you talk to him? Read him books? Tell him stories? madalas naming siya kinakausap, minsan binabasahan na rin ng books na pambata How do you talk to him? kinakausap ko siya ng normal, hindi yung baby talk, para alam niya yung tama paraan nang pagsabi ng salita

4.

Analysis:

Readiness for enhanced Speech and Language development

IX. Moral Development disiplinado naman siya nakikinig siya pag pinagsasbihan pinapagalitan ko kasi pag may nagawa siyang di maganda, minsan napapalo ko kapag sobrang kulitbinibigyan ko siya ng premyo or kahit anong gusto niya pag mabait siya.. Alam niya na yung tama sa mali.. May time na nagagalit siya pag di nakukuha gusto niya. Pag nakikita niya na pinagsasabihan ko ate niya, parang naawa siya, na nagagalit sa akin, kasi piagsasabihan ko yung ate niya. Analysis: Readiness for enhanced coping

X. Spiritual Development Baby pa lang siya sinsama na naming siya sa simbahan, para masanayKatoliko kasi kami. Tapos nagdarasal naman siya, kasama kami bago matulog, bago kumain.. Tapos, nagmamano na rin siya pag dumarating papa niya, basta sa mga nakakatanda, nakikita nya kasi sa mga kapatid niya. Analysis: Readiness for enhanced spiritual development

ASSESSMENT Health Supervision S: Pinapacheck up namin siya sa health center, kaso lang nahihirapan kaming dalhin siya doon kasi natatakot na siya sa mga doctor, nurse kasi nung nagkasakit siya natrauma siya sa mga injection at sa mga ginawa ng mga doctor sa kanya. As verbalized by the mother.

NURSING DIAGNOSIS Moderate Anxiety related to health interaction

SCIENTIFIC RATIONALE A Feeling of apprehension caused by anticipation of danger or fear.

GOALS AND NURSING OBJECTIVES INTERVENTION Goal: After 3 days nursing intervention, the mother will be able to reduce the anxiety level of the client from moderate to mild anxiety. Monitor the vital signs

SCIENTIFIC RATIONALE

EVALUATION After 3 days of nursing intervention, the mother was able to reduce the anxiety level of the client from moderate to mild anxiety.

To identify the physical response associated with both medical and emotional condition. To reduce level of anxiety by relieving tension.

(page 88, nurses pocket guide, 11th edition)

Encourage the client to have any activity or exercise program. (like playing with toys) Explain thoroughly the benefits of the procedure to the client Assist the client to use anxiety for coping with the situation, if helpful.

Objective: After 8 hours of nursing intervention, the mother of the client will be knowledgeable about the different healthy ways to deal with anxiety.

To help the client to identify what is reality based. The mother of the client was knowledgeable about the different healthy ways to deal with anxiety. The mother of the client is able to assume responsibility for the clients health care needs within level of ability.

To heightens awareness and permits the client to focus on dealing with problem.

O: There is a poor eye contact , presence of quivering voice, and facial tension. The heart is 125 Beats per

Observe behavior of the client.

To assess the clients level of anxiety

Encourage the client to express her fear.

To assist the client to identify her feelings and begin to deal with

Prepared by: Olegario, Glory Ann D. BSN3- H30

ASSESSMENT Nutritional Pattern S: At ngaun naman ay nagkakakain na din siya ng mga sitsirya, mga candy at iba pang matatamis . As verbalized by the clients mother. O: The client is slouching while sitting on her mothers lap. Skin is warm to touch. Good skin turgor. Mucus membrane is pink and moist T- 35.9 C HR- 125 bpm RR- 29 bpm Weight: 26 lbs Height: 95 cm BMI: 13.095

NURSING DIAGNOSIS Nutrition Imbalanced: less than body requirement r/t knowledge deficit.

SCIENTIFIC RATIONALE Intake of nutrients insufficient to meet metabolic needs

PLAN Goal: After 3 days of nursing intervention, the client will: >Demonstrate progressive weight gain toward goal. >Demonstrate behaviors, lifestyle changes to regain appropriate weight. Objective: After 8 hours of nursing intervention, the mother of the client will: >Define what nutritious food is. >Enumerate disadvantages of junk foods >Enumerate alternate healthy snacks that satisfy clients appetite.

INTERVENTION Monitor vital signs.

RATIONALE >Vital signs are an important component of patient care. They determine which treatment protocols to follow, provide critical information needed to make life-saving decisions, and confirm feedback on treatments performed. >To provide comparative baseline >To appeal to clients likes and dislikes >To identify cultural/religious influences that may affect food choices >To enhance food satisfaction and stimulate appetite >To enhance intake

EVALUATION After 3 days of nursing intervention, the client was able to: >Demonstrate progressive weight gain toward goal. >Demonstrate behaviours, lifestyle changes to regain appropriate weight.

(page 332, nurses pocket guide, 8th edition)

Assess weight, age, body build, strength and activity/rest level Discuss eating habits, including food preferences Determine psychological factors, cultural or religious desires Advice the mother to use flavoring agents Promote pleasant, relaxing environment, including socialization when possible Minimize unpleasant odors/sights

>To prevent any negative effect on appetite.

Prepared by: EAMILAO, Sylvia Angeli M. BSN3-H30