FATHER SATURNINO URIOS UNIVERSITY

San Francisco St. Butuan City 8600, Region XIII Caraga,

Philippines
Nursing Program

INDIVIDUAL CASE STUDY

TOODLER: GROWTH AND DEVELOMENT

May Chelle O. Erazo

Level II student

Ms. Nathalie Fat

Supervising Clinical Instructor
I. INTRODUCTION

This case study examines the overall status of a child. This study tends to know the past
history, family history, personal/social history and health history of a child. The researcher provided
a questionnaire to be answered by the mother of the child and through this the researcher can
formulate a nursing diagnosis and examines any abnormalities of the child by the assessments in
physical, developmental milestone and comparative study that will be the basis in formulating a
nursing problem and care plan.
II. NURSING HEALTH HISTORY AND PHYSICAL ASSESSMENT

As the mother indicated in the questionnaire, she started a prenatal check ups for five month s
of gestation and continuously doing it every month for the first trimester and every week for the third
trimester. The mother also indicates of having a full-term. The pregnancy status of the mother is 1
term, 0 preterm with a 0 abortion. The mothers’ frequency of prenatal check-up was seldom. The child that
is being examine is 35 weeks during the labor through spontaneous labor and delivery in the
hospital which has unassisted. As the baby is out after 19 hours, the baby cries high-pitched with no
presence of congenital abnormalities and perform the first breast feeding 2 hours after birth with 1
year and 2 months of weaning and a supplemental feeding of fruits and mashed vegetables. The
child often urinates without bed wetting.

The child’s mother is a student/housewife and his father is a time keeper, he is the only
child and they live as a nuclear family. The primary caregiver and prepares food for the child is the
mother and the child also sleep with them. There are only 3 people in their house with a 1 bed
room. The parent’s religion is Born Again Christian with a civil status of married. The source of water
supply in the family is Butuan City Water District Drinking Water with a Mineral drinking water.
The child was hospitalized in their local hospital due to Dengue Fever. He is also fully
immunized. In the age of 3 months, the child able to smile. In 6 months, the child can roll over and sit
unsupported. In 6 months, the child can hold head steady while in sitting position, in 8 months he can
sit with support and utter any first word with meaning in 7 months. In the age of 10 months, the child
able to stand with support. When the child is 1 year old, he can stand and walk alone and can talk in
sentence when he was 4 years old. Also the child able to dress himself and started a toilet training at
age 3 with an indication of the child’s approach and attitude,”Masinupakon ug matinumanon” as
verbalized by his mother.
III. DEVELOPMENT MILESTONES

DEVELOPMENTAL NORMAL ACTUAL INTERPRETATION

MILESTONE
PHYSICAL GROWTH The child learns to Child is 2 years and 5 We can say from the
climb up stairs first, months old. The child data that the baby’s
then down, stand and can stand and walk physical growth is
walk alone. alone. There is no somewhat normal but
information indicated we can’t formulate any
The child tends to gain about the height and other interpretation
about three to five weight of the child. since there is no data
pounds and grow about the weight and
three to five inches Height of the child.
GROSS MOTOR The child can start The child tends to run The coordination of
SKILLS walking around the house, larger muscle groups
independently, squat chases off dogs and of the child is normal
to play, throw ball, wanders around their as he can walk and
jump and run, crawl neighborhood. stand alone.
up stairs and creep
back down.
FINE MOTOR SKILLS The child can build The child usually A child is normal, he
block tower, scribbles plays with his toys can completely
on paper, eats with a and holding his coordinate with his
spoon, turns one page mother’s cellphone for hands, fingers and
of a book at a time and entertainment wrists.
holds crayon with
fingertips and thumb.

LANGUAGE/SPEECH The child can use The child utter words As evidenced, the child
simple phrases, such and talk in sentences can utter words and a
as "more milk", ask without any stutters. full sentence it
one- to two-word indicates a fine
questions, such as "Go language or speech
bye-bye?", follow skills. It is normal for a
simple commands and 5-year-old.
understand simple
questions, speak about
50 or more words and
be understood at least
half the time by
parents or other
primary caregivers
COGNITIVE The child able to utter The child utter words The child can utter
DEVELOPMENT 2-word phrases, uses and talk in sentences. words and a full
more complex toys sentence, so, he has a
and understand develop cognitive as
sequence of putting appropriate on his age.
toys, puzzles together
EMOTIONAL The child will feel There is no indicated As there is no
DEVELOPMENT pride when they are data about the indicated data about
‘good’ and emotional status of the the emotional status of
children the child, we can’t
 embarrassment when Formulate a data. But
they are ‘bad’ on the child’s age, he is
like to be clingier in
The child can the parents and
recognize distress in exhibits a territorial
others-beginning of mood.
empathy

The child is
emotionally attached
to toys or objects for
security
SOCIAL The child able to He is described as a The child is active in
DEVELOPMENT imitate, parallel and friendly and ongoing socializing. Since he
symbolic, play. person in their tends to wander
Showing an interest in neighborhood. around their area, he
others is a key part of has a lot of friends. He
socialization, and kids tends to be shy if he
will begin to seek out meets a new person,
interactions beyond but as her mutter
those with Mom and claimed that once he
Dad. knew that person he
will be able to interact
with him/her.

IV. COMPARATIVE STUDY

THEORY ACTUAL OBSERVATION INTERPRETATION

Erik Erikson’s Stages According to the parent, the The child is exhibiting a normal
of Psychosocial child already started to have development as mention by
Development the ability to help dress and the Erik Erikson’s Stages of
undress himself, able to ride a Psychosocial
Stage 3: Initiative tricycle, and play with other Development which is the
versus Guilt children. stage 3: initiative versus guilt
According to Erikson, children where he can act grown-up and
assert themselves more do things beyond his
frequently through directing capabilities.
play and other social
interaction. These are
particularly lively, rapid-
developing years in a child's
life.
Sigmund Freud The child is more attached to As the Sigmund Freud
Psychosexual Stages his mother. Psychosexual Stages identifies
that the child is in phallic
Phallic Stage stage,the child is more
The child is more focused on attached to his mother than
identifying with the same-sex his father. He could also lead
parent. At this stage, boys may to adult personalities like
develop what Freud referred to being sexually aggressive.
as an Oedipus complex.
 Jean Piaget’s Theory
of Cognitive Development
Concrete Operational Stage
The was able to understand
the things around him, stop
and think before doing
anything, and his logical ability
or thought begins to classify
objects by their similarities
and differences.
Exhibit an ability of knowing
the numbers, and remote
control toys. He tends to learn
about how things work.
The child is exhibiting an
ability of knowing the
numbers, and remote control
toys which is an indication of a
expected actions or ability of a
5-year-old child. The child also
uses his logical and coherent
thought in this action and also
has the potential in solving
problems involving the
physical world.

Lawrence Kohlberg’s No information being indicated As there is no indicated

Stages of Moral information that can anchor to
Development this theory, we can’t formulate
any diagnosis or interpretation
Level 1: about the child. But usually a
Preconventional child with this stage, they are
able to obey and understand
At the preconventional level the rules of punishing a child.
children don’t have a personal
code of morality, and instead
moral decisions are shaped by
the standards of adults and the
consequences of following or
breaking their rules.

Stage1: Obedience and

Punishment
Orientation.

The child/individual is good in

order to avoid being punished.
If a person is punished, they
must have done wrong.

V. NURSING CARE PLAN

1. Skin infection related to skin allergies.

2. Risk for abdominal pain related to food intake.

3. Risk for cough and cold related to weather condition.

4. Risk for dengue fever related to a poor environmental sanitation.

5. Risk for urinary tract infection related to family history.

Assessment Nursing Planning/Goal Nursing Rationale Evaluation
Diagnosis Intervention

Subjective Skin After a week of 1. Do an - So, we can After a week of

Cues: Infection nursing assessment on formulate a nursing
intervention, the child skin baseline data on intervention, the
Skin child will be able integrity. diagnosing the child will
allergie to minimize his child. gradually lessen
s skin infection. the infection of
2. Identify what - So, we will his skin and will
triggers the know where to be free from risk
child’s allergy. start the on skin infection.
intervention as
what it triggers

3. Allocate a - By this, you will

time to talk with have a chance to
a child about his communicate on
infection. child on what’s
going on his
skin or
why/how he
have that. You
can also observe
the way how he
talks and act, so
that you will
additional
information.

4. Talk to the - Being the

parents about primary care
what they can provider, they
do to avoid the are the one that
infection and is so close in
always pay their child
attention on almost all the
child’s body time, so they
and its physical can easily
appearance for observe the
some other child and they
existing can also
infections. perform the
suggested
intervention
easily as the
child trust them
more.
Assessment Nursing Planning/Goal Nursing Rationale Evaluation
Diagnosis Intervention
Subjective Cues: Risk for After a week of 1. Assess the child’s - To see any After a week of
abdomin nursing intervention, abdomen and infection or nursing
Food intake al pain the child will be able determine the bowel intervention,
to minimize the pain foods source of its abnormalities the child
of his abdomen. pain. in the minimized the
abdomen of risk of his
the child abdominal pain.

2. Lessen the oil - Foods

and can goods containing
intake. high
3. Avoid fast amounts of
foods such as fat, can slow
chips, hot dogs, stomach
ice cream, and emptying. In
etc. turn, food
spends more
time in your
stomach,
which can
cause
bloating,
nausea, and
stomach
pain

4. Advice the - To make

mother to provide sure its
healthy foods like sanitation
vegetables and and it is
homemade foods. healthier
than the
process
food.

5. Provide a meal - By this,

plan to serve as a the child
guidance in every will be able
meal a day. to maintain
the capacity
of its food
intake and
to avoid
over eating.
 VI. LEARNING OUTCOMES

The study was effective because we were able to assess the various eating patterns of the
children and decide whether they were normal or not. We were able to identify many risk factors
based on the information gathered from the mother's responses to the offered questionnaire. As a
result, we developed a 2-nursing care plan for the child, which included various interventions to
assist the child in resolving the problem. Furthermore, we do have limitations in diagnosing in
interpretation due tolack of information indicated in the questionnaire, but overall the child is
normal according to his age in developmental milestone that he exhibits.

References:
https://www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-
health/expert-answers/toddler-speech-development/faq-20057847
http://www.kamloopschildrenstherapy.org/gross-motor-skills-milestones-
toddler
https://www.healthline.com/health/fine-motor-skills#fine-motor-skills-
timeline
https://www.rsd.k12.pa.us/Downloads/Development_Chart_for_Booklet.pdf
https://www.parents.com/toddlers-
preschoolers/development/social/social-development-milestones-ages-1-
to-4/
https://www.simplypsychology.org/Erik-Erikson.html#autonomy
https://flo.health/being-a-mom/your-baby/growth-and-
development/psychosexual-stages-by-sigmund-freud
https://www.simplypsychology.org/piaget.html
https://www.simplypsychology.org/kohlberg.html
https://www.mayoclinic.org/healthy-lifestyle/childrens-health/in-
depth/thumb-sucking/art-20047038
https://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-
answers/nail-biting/faq-2005854