I.

IDENTIFYING INFORMATION
CLIENT
NAME Child A
AGE 3 years old
MENTAL AGE 1 year old
BIRTHDATE October 11, 2016
BIRTHPLACE Butuan City
GENDER Male
RELIGION Catholic
NATIONALITY Filipino
CITY ADDRESS Josephine Homes, Butuan City
SCHOOL STEPS Early Intervention Center
INFORMANT Adult guardian

II. CURRENT ASSESSMENT

A. Physical
PHYSIOLOGIC NORMAL CHILD NURSING
MEASUREMENTS: IMPLICATION
Temperature 36-38°C 35.8°C Below normal
range because
of air-
conditioned
room.
Pulse Rate 80-120 beats/min. 95 beats/min. Within normal
range
Respiration 22-34 breaths/min. 24 breaths/min. Within normal
range
Blood Pressure 80-110/50-80 mmHg 90/60 mmHg Within normal
range
HEAD TO TOE ASSESSMENT
BODY PART NORMAL CHILD NURSING
IMPLICATION
Head Normocephalic with Head is round and Normal
smooth skull contour; measure 52.5 cm
absence of lumps; (normocephalic), no
and symmetric facial lumps and has
movements symmetric facial
movements.
Hair Color and length  Color is black and Normal
varies in race and length is short, evenly
gender; fine and distributed and no
evenly distributed; no signs of manifestation.
manifestation of lice.
Eyes No discharge; lids Eyelids close Normal
 close symmetrically; symmetrically; no
Sclera is white; discharge and edema;
Conjunctiva is shiny Sclera is white;
and pink or red; no conjunctiva is pink and
edema over lacrimal shiny; pupils constrict
gland; Pupil constricts upon reaction to light.
upon reaction to light.
Nose Nose is symmetric Nose is symmetric, no Normal
and straight; no discharge or flaring
discharge or flaring; and air moves freely
air moves freely as as the client breathes.
the client breathes
through the nares.
Mouth & Throat Lips are pink, soft and 10 upper and lower Normal
moist; has 20 teeth; lips and gums
deciduous teeth; are pink and moist with
gums are pink with no no signs of bleeding.
signs of bleeding.
Ears Color same as facial Ears are in line with Normal
skin; symmetric the lateral angle of the
position; pinna recoils eye; no discharges;
after it is folded; and child can hear
normal voice tones well.
audible.
Neck Muscles equal in size; Smooth, coordinated Normal
head-centered with muscle movements;
coordinated, smooth lymph nodes not
movements with no palpable; trachea is in
discomfort; lymph mid position.
nodes not palpable;
trachea is in mid
position.
Chest Full and symmetric Chest is symmetric Normal
chest expansion; skin without tenderness
intact; no tenderness and masses present.
and masses present. Skin and chest wall
intact.
Lungs No crackling sounds; Breathes without Normal
respiratory rate and difficulty; respiratory
rhythm are regular; rhythm is regular; no
eupnea crackling sounds
noted.
Heart Normal heart rate is Heart rate is 95 Normal
80 to 120 beats/ min. beats/min. with regular
with regular rhythm. rhythm.
Abdomen Prominent abdomen Abdomen is round and Normal
 (rounded); symmetric bigger than his chest
contour; relaxed with circumference,
smooth, consistent symmetric and
tension; and no relaxed; and uniform in
rashes and lesions color.
Back No lumps or No spinal deformities Normal
deformities; uniform in and uniform in color.
color; erect position,
cervical is concave,
thoracic is convex,
lumbar concave.
Upper Extremities Muscles are equal in Muscles are uniform in Normal
size with smooth color without swelling
coordinated deformities, and
movements; normally tenderness; shows full
firm and equal ROM with equal
strength on each body strength on each body
side; full ROM; able to side; flexes and
flex and extend arm; extends arms without
no swelling, difficulty.
deformities, and
tenderness.
Lower Extremities Muscles are equal in Muscles are uniform in Normal
size with smooth color without swelling
coordinated deformities, and
movements; normally tenderness; shows full
firm and equal ROM with equal
strength on each body strength on each body
side; full ROM; able to side; flexes and
flex and extend leg; extends legs without
no swelling, difficulty
deformities, and
tenderness.
Genitalia Skin is intact with no Not assessed
signs of inflammation;
smooth and semifirm.
Anus Skin is normally Not assessed
pigmented, moister
than perineal skin.

General Appearance:
Child has a proportionate body size with a prominent abdomen, friendly and energetic
but usually spits food out.

B. Neurologic
 NORMAL CHILD NURSING
IMPLICATION
Behavior A child this age is Child is energetic and Child’s behavior is
headstrong and wants to hold things that appropriate to age.
negativistic, active, are new to him but easily
mobile, curios and has gets distracted
a distinct decrease in sometimes. He usually
appetite. spits food if not guided.
Motor All joints are able to Child shows coordinated Motor function is not
Function move and function movements. altered.
effectively without any
discomfort.
Reflexes Reflexes respond to All reflexes are working Reflexes are
stimuli appropriately. well and responds to functioning well.
stimuli.
Sensory A child is able to see, Client has altered Client has a high
Function smell, hear, taste, and sensory function in sensory threshold
feel effectively. tasting since he spits out where he wants to eat
food if not guided. food that has a rough
texture.

C. Developmental
NORMAL CHILD NURSING
IMPLICATION
Gross Child can run, walk up Child is able to walk, Gross motor skill is
Motor Skill stairs alone, stand on one run and jump without not altered.
foot, and rides tricycle difficulty.
Fine Motor Makes simple lines or Child uses pincer grasp Fine motor skills are
Skill strokes with the use of a when picking objects improving.
pencil. and can color an object
using the pencil grasp.
Language Verbal language Child can speak one to There is a delay in
Skill increasing steadily; can syllable at a time and language skill but
speak two-word sentence; usually uses hand the child is
knows full name; can gestures when they improving in his
name one color and holds need something; can pronunciation.
up fingers to show age. name colors and count
numbers.
Personal A child becomes aware of Child calls every adult It indicates that the
Social Skill gender differences and male that he sees as child is longing for
may point to other “papa”. He can the presence of his
children and identify them differentiate a girl and a father.
as “boy” or “girl”; does not boy. He likes to play
share toys and are fond in puzzles.
 how things fit together.

III. PAST HISTORY

A. Feeding History
First feeding started 12 hours after birth
Method of feeding Bottle feeding
Type of Formula Infagrow
Amount and Frequency 100 ml; 4 times a day (QID)
Age of Weaning 4 months
Age of supplemental Few hours after birth
feeding
Vitamin Preparation Seven seas (syrup)
Dose and Frequency 5ml; twice a day (BID)
Diet Restrictions Child is restricted to eat chocolate
Food Preferences Vegetable soup, pork, chicken
Allergies:
Food None
Medications None
Others None
B. Health History
History of Hospitalization Last November 2016 when the child was 2 months old,
admitted at Manuel J. Santos Hospital due to chickenpox.
Immunization Complete with booster
Growth and Development:
Weight 22 kg.
Length 1.04 m.
Dentition:
Age of onset of primary 9 months
teeth
Age of eruption of first Not yet
permanent teeth
Present number of teeth:
Upper 10
Lower 10

Developmental Milestones

Smile 1 month

Hold steady 1 year

while sitting
Roll over 5 months
Sit with support 2 months

Sit 1 year
unsupported
Stand alone 1 year and 5 months

Utter first word 2 years

with meaning
Stand with 9 months
support
Talk in 3 years
sentences
Walk alone 1 year and 2 months

Dress self 3 years

Toilet training:

Age 3

Approach to Shows gestures that

and attitude/s indicates the need to
urinate and defecate.
Elimination pattern:

Stool: Number Once (OD)

of times a day
Time period of Morning
day
Urination: 3 times a day or more
Number of
times a day
Time period of Any time of the day
day
Bedwetting Nighttime

Sleeping Pattern

Time of sleep 10:00 pm

Time of waking 5 or 6 AM
up
Duration of 7-8 hours
nighttime sleep
Nap 4 hours

Habits: Security
Behavior blanket/toy/rituals
pattern
Unusual Bite things for fun and
movements shakes when he wants
to hug someone
C. Family History
Family pedigree
Name Degree of Relationship Age Health Education Occupation
Status
Amy Mother 37 Healthy College Accountant
graduate
Angel cousin 21 Healthy Secondary
level
Family disease and congenital anomalies None

D. Personal/ Social History

Personal caretaker of child Cousin-Angel
Food prepared by Mother
Sleeping arrangement available for the During morning- cousin; at night: mother
child
Number of rooms in the house 2
Number of persons in the household 2
Cultural and religious practices Follows the beliefs and practices of the
Catholics
Civil Status of parents Married
Source of drinking water Wilkins
Healthcare practices Follows the advices from the healthcare
professionals
Where to consult Hospital/ Physician
Medications taken first As prescribed by physician

CASE ANALYSIS
CONCERN AREAS EXPECTED/ CHILD NURSING
NORMAL IMPLICATION
BEHAVIORS
I.Physical Growth and Development
 a. General A child is leaner Child has a Indicates that
Characteristics and more prominent physical growth
muscular little boy abdomen walks begins to slow
that has a with a wide down which is
prominent stance. Child’s normal for a child
abdomen and appetite also this age.
usually waddle. decreases.
b. Height and Weight A child gains only Height is 1.04 Weight is
about 2.5 kg. and cm and weight is appropriate to
12 cm. 22 kg. height.
BMI is 20.34
Psychomotor Milestones
1. Gross A child can walk, Child is able to Gross motor skills
run, jump, and walk, run, and is appropriate to
rides tricycle. jump on his own. age.
2. Fine A child can make Child is able to Fine motor skills is
simple lines and color objects improving.
strokes with a using a pencil
pencil. grasp.
II.Developmental Theories
a. Psychosocial Autonomy vs. Child does not The child cannot
Development Shame and doubt- say “NO” and verbalize “NO”
(Erikson) a child wants to do chooses which because of a
things puzzles he likes delay in speech
independently and to play. but he shows
usually says “NO”. independence in
choosing what he
likes.
b. Psychosexual Anal stage- child Child is wearing Child should start
Development learns to control a diaper in being toilet-
(Freud) urination and school but not in trained.
defecation. home; shows
gestures when
he wants to
defecate.
c. Cognitive Pre-operational Child does not Let the child
Development thought period- show signs of express what he
(Piaget) child is egocentric egocentricity. feels.
and expresses
everything to
himself.
d. Moral Development Preconventional Child follows the Child needs help
(level 1) instruction of the to determine what
Punishment/ teachers. are right actions.
obedience
orientation- child
 follows what his
parents say.
III.Social Development
a. Play Parallel play- Child prefers to Behavior is
Children play play alone. appropriate to
together but not stage.
with one another.
b. Socialization Child is Child is excited Child wants to be
enthusiastic about to meet new friends with other
interacting with people. people which is
other people. appropriate to
age.
c. School adjustment A child is usually Child is able to Child wants to be
shy at first but then adjust at school in a new
interacts with other well. environment.
people and wants
to play puzzles.
IV.Health Promotion
a. Fears Separation Child does not Child is having fun
Anxiety- a child is show signs of in school
sad when parents separation
are not beside anxiety.
them.
b. Temperament Child goes into Child is quiet and Being quiet is a
temper tantrums not in the mood child’s way to
through kicking, to follow control himself.
screaming or instructions.
stomping feet.
c. Communication A child can Child expresses Child cannot fully
communicate needs using non- verbalize due to
through verbal and verbal cues and developmental
non-verbal cues. needs delay.
assistance in
verbalizing.
d. Discipline A child usually Child is provided Child follows
wants to things with reward for instruction when
their own way. him to listen to rewarded.
his guardian.
e. Nutrition and A child should Child eats foods Child’s nutrition
feeding consume foods included in the and feeding is
included in the five five basic food healthy and
basic food groups group and drinks effective.
and 8 glasses of milk every day.
water a day. Food are usually
prepared in small
sizes.
 f. Dental Health Child brushes Child is guided Child still needs
teeth every after by the teacher guidance in
meals. when brushing. brushing teeth.
g. Sleeping pattern Child should sleep Child sleep 7-8 Child’s sleeping
11 to 13 hours of hours every night pattern is normal.
sleep. and a nap for 4
hours.
h. Bowel and Bladder A child has night- Child still wears Child should start
Control time bladder diapers in school toilet training.
control. but not in home;
still experiences
bedwetting at
night.
i. Exercise Playing is usually a Child likes to run Child’s exercise
form of exercise. around and pattern is normal.
interact with
people.
V.Current Health Children this age Child is Child’s
Problems are vulnerable to energetic, runs environment
accidents. around the place should be
and sometimes modified.
falls.
VI.Child’s response to A child is usually Child cries Child has
hospitalization scared to go to the during hospital separation anxiety
hospital. stay. and doesn’t like
confined spaces.
VII.Support System Family is the one Child’s parents Child’s support
who supports child and guardian system is effective
physically, supports him and and facilitates
emotionally, follows the learning for the
mentally and instructions of child.
financially. the teacher for
the improvement
of the child.

References:
 Pillitteri, Adele, Maternal and Child Health Nursing, 8 edition, volume 1
th

 Kozier, et. al., Fundamentals of Nursing, 5 edition

th