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Assessment of Toddler

Assessment of Toddler

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Published by mitsuki_sylph

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Published by: mitsuki_sylph on May 26, 2010
Copyright:Attribution Non-commercial

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11/29/2012

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ASSESSMENT OF TODDLERName:
Hannah Joy Martinez
Address:
362 Brgy Sampaloc 1, Pala-pala, Dasmarinas, Cavite
Birth date:
November 25, 2008
Height:
88.5 cm
Weight:Heart Rate:
110 bpm
Respiratory Rate:
30 cpm
Temperature:
o
PERSONAL- SOCIAL
 The child is more interactive with other people although there is aslight anxiety when meeting strangers. She shows independence asevidenced by using the spoon by herself when eating, drinking from cup, andremoving her garments by herself. She can also imitate adults like doinghousework. She can do simple tasks like running an errand.
o
FINE MOTOR ADAPTIVE
She is able to scribble spontaneously and voluntarily. She attempts toimitate letters. She can make a tower of up to 4 cubes. She can hold a spoonwell but she still has problem controlling her hand movements. She is able toopen doors and small bottles.
o
GROSS MOTOR
She can walk alone and can walk upstairs and seats in chairs. She can runand jump. She can remove her garments without assistance. She can recoverfrom stooping
o
COGNITIVE
She uses trial and error to discover new characteristics of objects orevents. She is able to experiment to discover new properties of objects orevents. She is capable of space and time perception as well as objectpermanence.
o
LANGUAGE
 The child is able to say 2-3 related words. She is still slurry when makingsentences. She sometimes uses nonverbal cues for the adults to understand hermore. She still can’t write letters, but she knows how to scribble and sheattempts to imitate drawn/written objects.
o
NUTRITION
 The child is on the weaning process. She can eat rice, bread, meat, fruits,and vegetables, although her diet is composed mostly of milk. She is also fond of eating candies and sweet food.
o
PLAY 
She is used to parallel play. She seldom shares her toys to her playmatesbut plays willingly with adults.
o
ELIMINATION PATTERNS
 
She voids not less than 5 times a day. Her usual color of urine is lightyellow. She still voids in bed. She defecates at least once a day in the morning.Her fecal consistency is moist but formed, yellow to light brown in color.
o
DENTAL HEALTH
She lost her two deciduous teeth (upper central incisors). She has dentalcaries on almost all of her teeth. She merely brushes her teeth.
o
REST AND SLEEP PATTERNS
She sleeps at an average of 10-12 hours. She sometimes takes a napin the afternoon.
 
HEAD – TO –TOE ASSESSMENT
General Appearance-Gait- wide based gait-Posture- lordotic-Body Built- small, with absence of baby fats-Mood- happy and actively participating-Speech- speaks 2-3 words, slightly slurry-Heart Rate- 110 bpm-Respiratory Rate- 30 cpmSkin-Color- brown, darker in parts exposed to sunlight-Texture- smooth-Moisture- not dry-Odor- no odor-Thickness- thick for age-Turgor- good turgor-Edema- non-pitting-Temperature- warm to touchNails-Color- pinkish-Angle- <160 degrees-Shape- rounded, clean cut-Capillary Refill- comes back in <3Hair-Distribution- evenly distributed-Thickness- thick-Scalp Lesions- no scalp lesions-Infestations- no presence of infestations-Dandruff-no presence of dandruf-Use of Products/ Chemicals- uses shampooSkull-Shape- round and symmetrical-Fontanels- both fontanels are closed-Concussions- no concussions-Lesions/ Lacerations- no lesions/ lacerationsEyes-Vision Acuity- 20/20 vision-Tearing- no reports of tearing-Use of Glasses/ Corrective Lenses- doesn’t use corrective lenses-Shape- round-Light Accommodation- good light accommodation-Discharges-no discharges-Lid Margins- aligned-Eye Lash Distribution- evenly distributed-Conjunctivas- pinkish-Sclera- white-Pupils- reactive to light-Eye Movements- well coordinated

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