LORMA COLLEGES

PATIENT HEALTH HISTORY

RELATED LEARNING EXPERIENCE

PADILLA, Erynne Myka

STUDENT NAME: ROTATION: 1ST ROT AREA: ONLINE
A.
CLINICAL INSTRUCTOR:
YR LEVEL AND SEC: BSN II- PENDER DATES: SEPT 7, 2021
MR. AURELIO MANEGO

CASE SCENARIO:

Upon arriving at the Delivery Room, you are about to receive new born baby boy that is delivered
to a primigravid mother by normal spontaneous delivery. Immediately after birth the baby cries well
and appears normal. The baby has a lot of vernix and a blue mark is noticed over the lower back.
You as a student nurse, perform the Essential Intrapartum Newborn Care, that includes Thorough
drying of the newborn, immediately perform skin to skin contact with the mother by placing the
baby over the abdomen of the mother, properly timed clamping and cutting of the cord and
observe breastfeeding cues. During physical assessment, you note the breathing pattern, Heart rate,
Muscle tone, Reflexes and Skin color are all normal. Using APGAR score, you determine how well
the baby tolerated the birthing process and how well the baby is doing outside the mother's womb.
The baby vital sign is RR – 60cpm, PR – 160bpm, and temp is 36 degree. You also perform
Anthropometric measurements and the result is normal. The baby is boy weighing 3000 gms. By
hospital policy, with the supervision of your clinical instructor, you will administer 1 st dose of BCG
and Hepa B vaccine to a normal new born. Upon meeting the mother, at the recovery section she
told you that the baby did not properly suck her breast for breastfeeding. She is worried that the
baby might be hungry, she also expresses herself regarding newborn screening and immunization.
You then note the concern and give proper health education.

The pediatrician also assessed the term newborn using Ballard scoring after 1 day. For the physical
maturity. The skin is smooth and pink. Lanugo is abundant. Creases covers the entire sole. The
newborn has full areola. Open eyes and her ears are soft they do recoil easily. The testes is
pendulous.

Next is Neuromuscular maturity. The square window, is measured by bending the wrist and
visualizing how far forward the infant’s hands can go forward. The infant demonstrates a 30-degree
angle when assessing the square window. Arm recoil has much to do with the infant’s flexion. The
pediatrician actively extends the infant’s arm to straight position and letting go in order to evaluate
how far back to full extension the arm. The infant recoils to a 140-degree angle. Actively extending
the infant’s leg and placing the foot near the head may measure the popliteal angle. The infant
extends his leg to a 100-degree angle. The doctor checks the scarf sign. She extends the infant’s arm
across the body and measures how far across the elbow falls. The infant able to get his elbow to
midline. The last marker of neuromuscular maturity is the heel to ear sign. This sign is measured by
actively extending the infant’s foot and attempting to reach the ear. The infant can only extend his
foot to a right angle above his body.
A. BIOGRAPHIC DATA
- neonate gender: male

B. REASONS FOR SEEKING HEALTH CARE

- child delivery

C. PRESENT HEALTH HISTORY

- neonate is delivered by normal spontaneous delivery
- the neonate is a normal newborn
- administered immunization from hepatitis B (intramuscular) and BCG (intradermal)
- The neonate is assessed using the Ballard scoring after a day of delivery

D. PAST HEALTH HISTORY

E. FAMILY HEALTH HISTORY

- The neonate is the 1st child of the mother; the mother is primigravid

F. LIFESTYLE AND PRACTICES

1. DESCRIPTION OF TYPICAL DAY
2. NUTRITION
3. ACTIVITY LEVEL AND EXERCISE
4. SELF-CONCEPT
5. RELATIONSHIP
6. STRESS LEVEL
7. ENVIRONMENT
8. EDUCATION AND WORK
9. VALUES AND BELIEFS
10. SLEEP AND REST

G. DEVELOPMENTAL STAGE
- Physical maturity and Neuromuscular maturity is normal after a day of delivery.