Beruflich Dokumente
Kultur Dokumente
I. Physical Developmental Demonstrate physical growth (weight, length, head and chest circumference) within normal range Manifest vital signs within normal range for age Exhibit vision and hearing abilities within normal range
II. Motor Development Perform gross and fine motor milestones within the normal range for age. For example, by 3 years of age, is the toddler able to do the following? a. Walk up steps without assistance b. Balance on one foot, jump and walks on toes c. Copy a circle d. Build a bridge from blocks e. Ride a bicycle
III. Psychosocial Perform psychosocial development milestones for age. For example by 3 years of age is the toddler able to do the following? a. Express the likes and dislikes b. Displays curiosity and ask questions
c. Accept separation from mother for short periods of time d. Begin to play and communicate with children and other outside the immediate family e. Understand words such as up, down and cold, hungry f. Speak in sentence of three to four words g. Imitate religious rituals of the family
IV. Development in Activities of Daily Living Feed self Eat and drink a variety of foods Begin to develop bowel and bladder control Exhibit a rest and sleep pattern appropriate for age Dress self
Client's Name: Franzen Rhiell Gorgonio Date of birth: June 22, 2010 Father's Name: Leo Anthony C. Barbo Occupation: None Mother's Name: Anne Arianne V. Gorgonio Occupation: Student
Sex: Male
I. Birth and Maternal History 1. Antepartal: Age of mother when pregnant with this child? 17 yrs old OB score then? G1P1 Had prenatal check up? Yes Complications during her pregnancy, if any, like hypertension, edema, infections, etc? None Medications taken? Ferrous Sulfate
2. Interpartal: AOG? 36-37 weeks Presentation? Cephalic Duration of labor? Every 1 min. Type of delivery? Normal Anesthesia used? None Who attended delivery? Mother & Father
3. Postpartal: Did this child cry immediately? Yes Any cyanosis? None Jaundice? None Resuscitative measures done? No Difficulty in feeding? No Number of days in the hospital? 3 days
A. General Assessment
Findings
Norms
Height Weight Head Circumference Chest Circumference Temperature Pulse Rate Respiratory Rate Blood Pressure
80 cm
Findings
Norms
C. Motor Development
Able to Perform
How elicited
Yes No
A. Neurological Assessment
Reflexes
How Elicited
Findings
Norms
Interpretation
Rooting Reflex If the cheek is brushed near the mouth, the newborns head will turn to that direction
Normal
1. Nutritional Pattern Breastfeeding: FrequencyDuration- If he is already hungry Reaction to breastfeed- Good Formula Feeding: Brand of milk- Bona Quantity per feeding- 3 ml per bottle
Number of feedings/day- 7-8 bottles Schedule- Every 3 hours Change in formula and why- Nestogen then Bonamil Age weanedSupplementary Feeding: Age when first given solid foods- 6-7 months First solid food given- Banana, Potato & Squash Solid taken at present- Rice, Chicken, Banana, Etc. How often- Sometimes Food likes- Banana, Chicken, Bread, Rice, Etc. Dislikes- Some vegetables How is his appetite- Good Presence of any food allergy- None
Analysis:
2. Rest and Sleep How long does he sleep at night? 8-9 hours During the day? Every 2-3 hours How do you put him to sleep? Supine/Side lying position How does he wake up? If he is already hungry
Analysis:
Is oral care provided? No Does the child look neat and clean? Yes Properly dressed? Yes Any problem related to hygiene? No How manageds? Change his dress twice a day
Analysis:
4. Elimination Pattern Bowed: ConsistencyColor- Yellow green Odor- Slightly foul smelling FrequencyControlBladder: FrequencyColor- Yellow ControlElimination problem encountered by parents? None
Analysis:
5. Health Supervision Is the baby brought regularly to the well-baby clinic? Yes How is health of the baby maintained? Good
Analysis:
III. Emotional Assessment 1. Can you meet readily the needs of your baby (feeding, changing diapers, etc)? Yes 2. Do you have a schedule of your babys daily activities? Yes 3. Does your baby sleep soudly? Yes 4. Do you always talk to your baby? Yes 5. Do you always kiss, hug, and touch him? Yes 6. When your baby cries, do you go to him right away? Yes How do you pacify him? By approaching him 7. Do you wake up at night to check your baby? Yes 8. Who takes care of your baby most of the time? My mother 9. How many hours do you allot for taking care of your baby? At night only 10. Do you encourage/allow him to sits up, stand up, walk, and do other activities? Yes 11. How does your child react when you give attention to other children? Jealous 12. How does your baby behave when you leave the house without him? Crying 13. How does he react when he is being teased? Sad 14. What does he do when he wants to be carried but you did not carry him? Crying 15. What does he usually do if his wants are not granted? Crying 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? Yes 17. Do you allow him to play while being bathe? Yes
Analysis: