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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 a slight anxiety when meeting strangers. She shows independence as evidenced by using the spoon by herself when eating, drinking from cup, and removing her garments by herself. She can also imitate adults like doing housework. She can do simple tasks like running an errand. FINE MOTOR ADAPTIVE She is able to scribble spontaneously and voluntarily. She attempts to imitate letters. She can make a tower of up to 4 cubes. She can hold a spoon well but she still has problem controlling her hand movements. She is able to open doors and small bottles.
GROSS MOTOR She can walk alone and can walk upstairs and seats in chairs. She can run and jump. She can remove her garments without assistance. She can recover from stooping o COGNITIVE She uses trial and error to discover new characteristics of objects or events. She is able to experiment to discover new properties of objects or events. She is capable of space and time perception as well as object permanence. o LANGUAGE The child is able to say 2-3 related words. She is still slurry when making sentences. She sometimes uses nonverbal cues for the adults to understand her more. She still can’t write letters, but she knows how to scribble and she attempts 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 playmates but plays willingly with adults. o ELIMINATION PATTERNS o
She voids not less than 5 times a day. Her usual color of urine is light yellow. 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. DENTAL HEALTH She lost her two deciduous teeth (upper central incisors). She has dental caries on almost all of her teeth. She merely brushes her teeth. o o REST AND SLEEP PATTERNS She sleeps at an average of 10-12 hours. She sometimes takes a nap in 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 cpm Skin - 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 touch Nails - Color - pinkish - Angle - <160 degrees - Shape - rounded, clean cut - Capillary Refill - comes back in <3 Hair - Distribution - evenly distributed - Thickness - thick - Scalp Lesions - no scalp lesions - Infestations - no presence of infestations - Dandruff -no presence of dandruff - Use of Products/ Chemicals - uses shampoo Skull - Shape - round and symmetrical - Fontanels - both fontanels are closed - Concussions - no concussions - Lesions/ Lacerations - no lesions/ lacerations Eyes - 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
Ears - Texture - smooth - Alignment - aligned to canthus - Discharges - no discharges - Hearing Deficits - no reports of hearing deficits - Lesions - no presence of lesions - Infections - no ear infections - Piercings - one on each ear - Ear Cleaning - twice a week Nose and Sinuses - Symmetry - symmetrical, midline - Discharges - no discharges - Lesions - no lesions - Polyps - no polyps - Nasal Flaring - no nasal flaring - Obstructions - no obstructions - Snoring - no reports of snoring Mouth - Lips - pinkish, smooth, moist - Gums - pinkish - Dentures - no dentures - Toothaches - had reports of toothaches - Dental Caries - almost all teeth - Mouth Sores - no mouth sores - Dental Habits - merely brushes her teeth - Lesions - no lesions - Tonsils - not enlarged - Uvula - midline, not enlarged Throat and Neck - Symmetry - midline - Change in voice - no change in voice - Hoarseness - no hoarseness - Sore Throat - no reports of sore throat - Pain/Stiffness - no reports of pain/ stiffness - Dysphagia - no difficulty in swallowing - Lumps - no lumps Breast/ Axilla - Symmetry - symmetrical - Nipples, Areola, Discharges - no discharges - Pain - no reported pain - Tenderness - no reported tenderness - Lumps - no lumps - Rashes - no rashes Chest and Respiratory - Symmetry - symmetrical - Breath sounds - no breath sounds - Breathing patterns - regular - Chest pain - no reports of chest pain - Dyspnea - no reports of difficulty in breathing
- Orthopnea - no orthopnea Cardiovascular and Peripheral - Color of Extremities - extremities are warm to touch - Heart Murmurs - no heart murmurs - Chest Pain - no reports of chest pain - Heart Disease - no reports of heart disease Abdominal/Gastrointestinal - Shape - prominent abdomen (pouchy belly) - Texture - smooth - Pain - no reports of abdominal pain - Appetite - no reports in change in appetite - Usual bowel habits - once a day in the morning - Changes in stool color - no changes in stool color - Stool Characteristics - moist but formed, yellow to brown in color - Distention - no distention - Flatulence - no reports of flatulence Reproductive - Lesions - no lesions - Discharges - white and minimal Genitourinary - Urine color - light yellow - Voiding patterns - not less than 5 times a day - Dysuria - no difficulty in voiding - Urine Retention - good urine retention - Flank Pain - no reports of flank pain Musculoskeletal - Joint stiffness - no joint stiffness, joints can be flexed without difficulty - Range of Motion - full range of motion - Deformities, dislocations, and fractures - no deformities/ dislocations/fractures - Pain - no reports of pain - Weakness - child is active Hematological - Bruising - no bruises - Bleeding - no bleeding present - Blood Type Lymph Nodes - Enlargement - not enlarged - Tenderness - non-tender
MMDST PERSONAL-SOCIAL • Imitates housework –pass – the caregiver reports that the child imitates housework like sweeping the floor • Uses Spoon, Spilling Little – pass – the caregiver reports that the child can use spoon while eating, but still spills some food • Helps in House, Simple Tasks – pass –the child can do simple errands like handing over an object • Drinks from Cup – pass – the child can drink on a cup without handle without difficulty • Removes Garment – pass - the caregiver reports that the child can undress herself • Plays ball with examiner – pass - the child throws the ball to the examiner FINE MOTOR ADAPTIVE • Scribbles Spontaneously – pass – the child scribbles lines when given a pencil and a paper • Tower of two cubes – pass- the child can make a tower of two cubes • Tower of four cubes – pass – the child can make a tower of four cubes after two trials • Dumps Cheese Curls from bottle – demonstrated – pass – the child dumps the cheese curls from the bottle after demonstration • Dumps Cheese Curls from bottle spontaneously – pass – the child dumps the cheese curls spontaneously the second time without being told LANGUAGE • Three words other than mama/ papa – pass – the caregiver reports that the child can speak three related words other than mama/papa • Points to one named body part – pass – the child pointed to her eyes when the examiner told her to • Combines two words – pass - the caregiver reports that the child can combine two related words for others to understand her • Names one picture –fail – after three attempts, the child was only able to mimic the sound it does rather than telling what it was • Follows Directions – pass – the child was able to follow directions when the examiner told her to hand over the blocks to her GROSS MOTOR • Kicks ball forward – pass – the child was able to kick the ball toward the examiner • Walks well – pass – the child can walk well without assistance • Walks backward – pass- the child can walk backward without falling • Walks up steps – pass – the caregiver reports that the child can climb up stairs • Stoops and recovers – pass – the child did not fall when picking up a toy • Throws ball over hand – pass – the child was able to throw the ball over hand
Balance on one foot for 1 sec. – fail – the child could not balance on one foot Jumps in place – pass –the child was able to jump in place when she was told to
Subjective Data: Caregiver verbalizes that her child sometimes has toothaches Caregiver reports the child’s dietary habits (eats more candies and sweet milk) and oral hygiene (merely brushes her teeth) Objective Data: Tooth enamel discoloration Erosion of enamel Crown and root carries on almost all teeth Premature loss of primary teeth (upper center incisors) Incomplete eruption of teeth for age (deciduous teeth are 18, 2 upper center incisors fell out) Assessment: Impaired dentition r/t dietary habits, ineffective oral hygiene, and lack of knowledge regarding dental habits Planning: At the end of the shift, the client will be able to: - verbalize and demonstrate effective dental hygiene skills At the end of the shift, the caregiver will be able to: - verbalize understanding of the importance of oral health - encourage and assist the client in her dental hygiene and set as an example to her - follow through on referrals for appropriate dental care Intervention: 1. Note presence/ absence of teeth and ascertain its significance in terms of nutritional needs and aesthetics. Rationale: For formulating plan of care and for finding ways on enhancing client’s confidence 2. Evaluate current status of dental hygiene and oral health. Rationale: For formulating plan of care 3. Treat/ manage dental care needs through: a. Administering saline rinses Rationale: Gargling normal saline helps prevent upper respiratory conditions (e.g. colds, sore throats) b. Providing gentle gum massage with soft toothbrush Rationale: Promotes oral health c. Assisting/ encouraging brushing at least twice a day. Rationale: For optimum oral health d. Advising minimal intake of sugary foods and more on foods rich in protein, carbohydrates, vitamins and minerals, especially calcium-rich food. Rationale: For optimal nutrition and for oral health promotion 4. Promote wellness through client/caregiver teaching by: a. Instruct client/ caregiver in home care interventions Rationale: To treat condition and/or prevent further complications b. Review resources that are needed for client to perform adequate dental hygiene care Rationale: For client’s knowledge and accessibility to the needed resources c. Discuss advisability of dental check-ups Rationale: To minimize oral/ dental damage.
Subjective Data: Caregiver verbalizes that her child is able to speak but is still slurry when composing sentences Objective Data: Able to speak a language Forms small words and phrases Uses and interprets nonverbal cues appropriately Imitates written letters though letters are not well formed Assessment: Readiness for enhanced communication r/t development in child’s language and cognition Planning: At the end of the shift, the caregiver will be able to: - Verbalize/ indicate understanding of techniques that will assist the client to learn/ comprehend on communication lessons At the end of the shift, the client will be able to: - Express information/ thoughts/ feelings in a satisfactory manner - Write at least her first name Intervention: 1. Determine client's ability to write and comprehend Rationale: To evaluate the client’s grasp of knowledge 2. Improve client’s ability to communicate thoughts, needs, and ideas by: a. Maintaining a calm, unhurried manner. Rationale: For client comfort b. Sitting down and maintaining eye contact. Rationale: To establish trust with the client c. Paying attention to the client. Rationale: To establish trust and rapport with the client, and to make her feel that she is heard d. Observe body language, eye movements, and behavioral cues. Rationale: May reveal unspoken concerns e. Establish hand and eye signals if necessary. Rationale: To enhance understanding and to enhance cooperation and interest f. Provide writing and other learning materials (e.g. picture boards) Rationale: To enhance learning and interest in learning g. Reduce distractions and background noises Rationale: Distracting environment can interfere with communication, limiting attention to tasks, and making speech and communication more difficult. Reducing noise can help both parties hear clearly, thus, improving understanding. 3. Promote optimum communication by: a. Discussing with caregiver effective ways to which the client communicate Rationale: For effective communication on both parties b. Encourage client and family/ caregiver to use successful techniques for communication Rationale: Enhances family relationship and promotes self-esteem for all members
Subjective Data: The caregiver verbalizes that her child needs and is willing to be toilet trained The caregiver verbalizes that her child still voids in bed Objective Data: Client has developed micturation patterns and has learned how to control urgency except when sleeping Assessment: Readiness for enhanced urinary elimination Planning: At the end of the shift, the caregiver will be able to: - Verbalize understanding of client’s condition that has potential for altering elimination - Alter the environment to accommodate client’s needs - Assist the client in achieving normal and healthy micturation pattern Intervention: 1. Determine client’s voiding pattern and characteristics. Rationale: To provide baseline data 2. Regulate liquid intake at prescheduled times. Restrict fluid intake 2-3 hours before bedtime to reduce voiding at night. Rationale: To promote predictability of voiding patterns 3. Provide assistance/ devices as indicated (potty bowls/ urinals/”arinolas”) Rationale: for client comfort 4. Promote optimum wellness through: a. Encourage continuation of successful toileting program and identify possible alterations to meet individual needs Rationale: To promote pro-active problem solving and support normalization of activities b. Instruct client/ caregiver in cues (voiding on routine schedules, providing adequate room lighting, easy access to comfort room) that client needs to improve micturation patterns Rationale: To promote client comfort
RABE, BLAZEL EDVE MARIE T. II-BSN-3
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