LORMA COLLEGES CON TEMPLATE

PATIENT HISTORY
RELAED LEARNING EXPERIENCE

STUDENT NAME : Fronda, Aron John B. ROTATION: 1ST ROTATION AREA: NICU
CLINICAL Mrs. Marites
YR LEVEL AND SEC: BSN-II SCHOENHOFER DATES: February 7,8,9 and 14,15,16, 2022
INSTRUCTOR: Gallardo

A. BIOGRPAHIC DATA
Name: Wency
Gender: Female
Mother’s name: Sharon
B. REASONS FOR SEEKING HEALTH CARE
C. PRESENT HEALTH HISTORY
The baby was born by the mother who had cord prolapsed and delivered through C-Section.
D. PAST HEALTH HISTORY
E. FAMILY HEALTH HISTORY
F. LIFESTYLE AND PRACTICES
1. DESCRIPTION OF TYPICAL DAY
2. NUTRITION
Oro-gastirc tube was inserted to facilitate feeding of breast milk taken from her mother
at the amount of 20ml every 4 hours.
3. ACTIVITY LEVEL AND EXERCISE
4. SELF-CONCEPT
5. RELATIONSHIP
Sharon, a 37 year old mother of baby Wency.
6. STRESS LEVEL
7. ENVIRONMENT
8. EDUCATION AND WORK
9. VALUES AND BELIEFS
10. SLEEP AND REST
G. DEVELOPMENTAL STAGE
Trust vs. mistrust is the first stage in Erik Erikson’s theory. This stage begins at birth continues to
approximately 18 months of age. During this stage, the infant is uncertain about the world which they live,
and looks towards their primary caregivers for stability and consistency of care.
 LORMA COLLEGES CON TEMPLATE
PHYSICAL EXAMINATION
RELAED LEARNING EXPERIENCE

STUDENT NAME : Fronda, Aron John B. ROTATION: 1ST ROTATION AREA: NICU
CLINICAL Mrs. Marites
YR LEVEL AND SEC: BSN-II SCHOENHOFER DATES: February 7,8,9 and 14,15,16, 2022
INSTRUCTOR: Gallardo

A. GENERAL ASSESSMENT
The baby was born at exactly 11:00 am. She has small muscle mass and lack of subcutaneous fat. She did not cry immediately after delivery. Based
from initial assessment, the neonate appeared pale and blueish, with weak pulses, poor perfusion with O2 Sat of 75, decreased capillary refill, and
persistent bradycardia with CR of 55. She has also minimal response to stimuli and muscle tone, respiration is absent coold touch with temperature
of 36 C. APGAR score was checked which is interpreted as “Severely Depressed”. The newborn also developed hypovolemic shock secondary to
blood loss cause by cord prolapsed.
B. SKIN, HAIR AND NAILS
The neonate appeared paple and bluish, with weak pulses, poor perfusion with O2 Sat of 75 and decreased
capillary refill. And turned pinkish
C. HEAD AND NECK
No presence abnormalities
D. EYES AND EARS
No presence abnormalities
E. MOUTH, THROAT AND SINUSES
Irregular breaths starts when patient’s APGAR scoring was assessed repeteadly
F. HEART AND NECK VESSELS
Patient’s initial assessment, the neonate was assesssed with weak pulses, persistent bradychardia with CR of 55.
Then eventually CR rate of 120. And became stable with heart rate of 140bpm.
G. ABDOMINAL ASSESSMENT
 No presence of abnormalities
H. EXTREMETIES
The neonate has a minimal response to stimuli and muscle tone. The second assessment tells that the neonate is till floppy.
I. GENITALIA
No presence of abnormalities
J. NEUROLOGIC
The patient did not cry right away after being born. Has poor sucking reflex.