Group 23 - Module 8

Davao Doctors College, Inc.
College of Allied Health Sciences

Nursing Program
NRG 203: CARE OF MOTHER, CHILD AND ADOLESCENT

(WELL CLIENTS) GROWTH & DEVELOPMENT OF TODDLER
All a Nurse Needs to Know about Maternal-Child Nursing
Getting to Know the Course Instructor
Hello! I am NIKKI LOU GAVIOLA-VIOLATA, and I will be your instructor for NRG 203: CARE
OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENTS); GROWTH AND
DEVELOPMENT - TODDLER.
For this semester, I will be your instructor for NRG 203: CARE
OF MOTHER, CHILD, AND ADOLESCENT (WELL CLIENTS);
GROWTH AND DEVELOPMENT OF TODDLER. I am looking
forward to guiding you in learning this course well. If you want to
reach me for any academic-related concerns, you can reach me
through the following:
Contact No: (per request)

Facebook account: Nikki Lou
E-mail address: nikkilouviolata@davaodoctors.edu.ph
Consultation hours: Wednesday 4:00 – 5:00 PM
Introduction to the Course

The course NRG 203: Care of Mother, Child and Adolescent: Growth & Development of a
Toddler deals with concepts, principles, theories and techniques of nursing care management of a
well children at a Toddler stage. In this course, you are expected to provide nursing care to children
utilizing the nursing process. Presented below are the specific details of this course:
Course Number: NRG 203
Course Credits 9 units (4 units Lecture, 5 units RLE)
No of Hours (Lab): (20 hours/week for 18 weeks)
Placement: Second year, First Semester
Prerequisite: NRG 105, NRG 106
Schedule: MTWThFS 7am-1pm; 1pm-7pm
GOOGLE CLASSROOM:
Classroom:
CLASS CODE:
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Requirements in Completing the RLE Activities
Since most of our sessions for this semester will be delivered through distance/blended learning
activities, the submissions will also be done online. To do this, you need to have access to the
following applications:
1. Microsoft Office/Google Docs

2. Google Classroom
3. Google Meet (or any other teleconferencing app, duly agreed by the whole class)
4. Internet connectivity
Access to a printer and/or scanner is also a plus, but not a requirement.
Daily Activities
Every week, you are expected to follow through the following deliverable:
Day 1 (Monday/Thursday) Day 2 (Tuesday/Friday) Day 3 (Wednesday/Saturday)

Virtual Circle Virtual Circle Virtual Circle
Completion of Module, to be Receiving of Handover Case Presentation (cont.)

submitted within the day
Case Presentation Weekly Quiz and Discussion of
Preparation of PPT Module and Quiz Answers
Presentation
Orientation of Next Week’s Activity
Now that you are done acquainting yourself with the instructor and the course itself, please proceed
to Module 5: Care of MOTHER, CHILD & ADOLESCENT (The Family with a Toddler).
Term: First Semester S.Y. 2022-2023

Dates: Week 12: November 7–9, 2022
Class Schedule: MTWTHFS: 7 AM-1PM ; 1PM-7PM
No. of Hours: 6 hours/meeting
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Instructions
The case analysis manuscript may be handwritten or computer written. Observe pagination.
Once done, send the compilation of your group’s answers to your clinical instructor.
After the submission, prepare a PPT presentation for your case presentation slated for Days 2 and
3 of your RLE classes. Each member of the group is expected to present during the case
presentations.
Learning Outcomes
At the end of this module, you are expected to:
1. Describe the normal growth and development of an infant as well as common parental
concerns.
2. Assess an infant for normal growth and development milestones.
3. Formulate nursing diagnoses related to infant growth and development or parental concerns
regarding growth and development.
4. Use critical thinking to analyze methods of care for infants to be certain care is family-
centered.
5. Identify expected outcomes for nursing care of an infant.
6. Plan nursing care to meet an infant’s growth and development needs, such as anticipatory
guidance to prevent problems such as sleep disturbances.
7. Implement nursing care to promote normal growth and development of an infant, such as
discussing infant developmental milestones with parents.
8. Identify areas related to the care of an infant that could benefit from additional nursing
research or application of evidence-based practice.
9. Integrate knowledge of infant growth and development with the nursing process to achieve
quality maternal and child health nursing care
As you start with this module, you are free to consult and coordinate with your assigned clinical
instructor. Be sure to get his/her email address and contact number for collaboration and
assistance. Just keep going, you can do it!
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Case Analysis:
The Family with a Toddler
Case Scenario: Second Degree Accidental burn at Right Hand
Course in the Ward

Marty, a 27 month old toddler was admitted to the ER due to 2nd degree burn. During the interview
the mother, Mrs. Lorraine said that she left Marty playing on the sofa while she was preparing their
lunch. She went outside the house to throw the garbage and suddenly she heard Marty crying in
pain. She then saw Marty near the frying pan and it seemed that Marty stood near the pan and
dipped his hand. According to the mother she never thought that Marty would be curious about
what she was doing and that he would climb up near the stove. “Wala gyud ko ngdahum nga
musaka na diay na sya ug iyaha bah, lihukan pud lagi bataa oi..naluoy jud ko pagkakita nko sa
iyaha nga pirti niyang tiyabaw. mao gidala nako dayun sya sa ospital.”
When asked what she did before going to the hospital, she said that she just placed the hand over
the running water, cleaned the burned area and called her husband, Mr. George to meet her at the
hospital.
You were assigned to Marty’s care and was asked to do a thorough assessment and to conduct an
interview regarding Marty’s growth and development. Lorraine states that they live with Marty in a
house with his father George, an industrial engineer, 35 yrs old, Lorraine is a stay at home mom,
32, who have been married for 12 years. Marty’s older brother, Josh is 7 years old and in the first
grade. Marty had a normal birth and his mother Lorraine mentioned that there were no
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complications or struggles during birth. Marty was born at 1:33PM on August 12, 2020 weighing
6.3 pounds. Marty now weighs 27.5 pounds. He got his first tooth at 6 months. He sat up by himself
and started crawling around eight months and was walking around at 13 to 14 months. One of the
recent activities that showcased his fine motor skills was his throwing a ball overarm in short
distances, stretching out arms to catch it, rolling the ball using the arms and hands and even kick-
in it. He does things with both hands, but most of the time he shows signs of being right handed.
He can do the puzzles that require putting pieces into an indented board, but he cannot do the
puzzles that create a whole picture yet. One area that Marty struggles with is being able to crawl
down stairs backwards. He probably would be able to do this but around 18 months, he fell down
a couple of stairs and now is scared, so he scoots on his bottom down the stairs. At this time his
parents are guiding Marty with his toilet training, he has a lot to learn to control his bladder and
bowel movement. He was always reminded by his mother to go to the toilet to pee or move the
bowel and eventually not use a diaper while at home.
Marty enjoys simple dances and rhythms especially when he hears music. One thing that he loves
more than anything is humming to the rhythm of the song and repeating what his mom Angie says.
He eats very well. He loves to munch steam carrots and fruits like apple and a piece of orange. He
has recently started to eat at the dinner table on a seat with the rest of the family. Marty still sleeps
through the night and then takes one hour to two hour nap during the afternoon. During his 2nd
birthday, his father George gifted him a ball that has different cut out shapes on it. He usually bonds
with his mom by playing with it. He then has to find the shape that correlates with the hole in the
ball and put the shape into the hole. One way his mom works with his cognitive development is by
having Marty name each color of the missing piece before he puts it into the ball. Marty is learning
and able to name at least 4 out of 8 different colors. When he draws he mostly scribbles and when
asked about what he drew, he does not answer, he only points at it and says his universal word,
“Josh” (his brother). He would also imitate others, one person that he imitates regularly is his
brother. He also learned how to put objects in and out of containers. He loves to play in the water
whenever he bathes every day, he learns how to put shampoo in his hair, make a bubble drop and
splashes the room with a lot of water. His mother will facilitate the proper final rinsing of water to
remove soap suds in his body. He knows how to dress himself with a simple shirt without a button.
Marty babbled loudly as an infant and his first word was “Dad” as Angie stated. At 24 months,
Marty talks with words and gestures. The words are not always clear, especially when he is excited.
His gestures mostly consist of pointing to objects in his story. He learned the word “no”, but did not
always respond to it. During the last couple of weeks, he has started to put together two or three
word sentences. One of them are “I out” “love you” and “I am Marty”. He does not like to sit still
enough for most stories, but he will watch “Frozen” over and over. He does not know the names
though. To him, it is called, “fishy”. He also likes Sesame Street, more specifically he likes Elmo
and he knows his name. If he sees the object get hidden he will look for it, but he will not just go
and look for an object if told, unless it is his shoes. Marty has started to show signs of memory and
assimilation. One example of this is since he has been told that pots and pans that his mom is
cooking with are hot, he told Josh that the pizza pan he was holding was hot. He just pointed and
said “hot, hot”. Marty will respond to simple directions. For example, if you ask him to pick up his
trash, like a wrapper, he will throw it away in the trash bin. He will also pick up his toys if instructed,
most of the time. He has also started to use problem solving to figure things out. His mother Lorraine
used to shut doors to keep him out of things, now he has figured out how to open doors so that he
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can still get to the things he wants and her mother will not let him have. Mrs. Lorraine also noticed
that he started to climb up the stairs and never imagined that he would climb over even up to their
stove because she clearly instructed their children not to go near the kitchen stove.
The family bonding for Marty started before he was even born by his father George talking to him
during the pregnancy. Lorraine avoided any possible teratogens and even avoided caffeine. She
also stated that she drank a lot of water and ate a lot of fruit during the pregnancy. Since Lorraine
reads to Josh every day, Marty got read to at the same time. Marty seems to be pretty open about
his emotions. When he is mad, he screams. When he is hurt, he cries. When he has done
something wrong and has gotten in trouble he simply looks down and gets sad. He has grown up
with mom Lorraine being home with him. Marty is known as a tornado, not because of temper but
because he is very energetic and into everything. He enjoys playing with everything from anyone’s
shoes to Little People toys. He enjoys being around people and has a blast playing with his toys or
with his family members. At times, whenever Marty gets upset and shows his frustrations, or resist
what his parents tell him to do like most children of his age. He show tantrums and can go through
many different moods within a short period of time. He does have a security blanket, and as long
as he has it he is usually okay. One Christmas break, the family hosted a small party with cousins
and friends. Marty is observed to be playing beside his cousin Ronan without interacting, but in a
few more minutes they will be imitating and copying what the other will be doing. When he is around
his cousin Ronan crying, he exhibits his caring attitude towards him by occasionally giving him his
blanket to try to calm him down. On one specific time, Marty threw a fit at McDonald’s because his
dad George would not let him hold his cup. His parents rule is he is not allowed to hold his cup
unless there is a lid on it, so he started throwing a fit by kicking and screaming but his dad
cooperated with him and calmed him down. The resolution was they would both hold onto the cup
as he took the drink.
Physical examination:
After endorsement you were asked to perform a physical assessment of Marty. During the physical
examination, Marty was crying uncontrollably and his mother and father were calming him down.
They were trying to give him his blanket but continued to be irritated and crying out of pain and
pointing towards his right hand. He has an IV in his left metacarpal vein, intact and patent with D5
LR 1 liter @ 112 ml/hour at a level of 950ml. His eyes were already swollen. There seems to be no
difficulty in breathing upon assessment. When the mother was asked how many teeth Marty has
she said that she counted recently and noticed he has around 20 teeth total. She was planning to
have him schedule a dentist appointment in the coming days. No other unusualities were noted at
the mouth. His skin is fair, soft and warm to touch. The affected hand started to have blisters,
redness is noted around the area and looks shiny. Aside from that there were no other unusualities
in the extremities. As soon as Marty quieted down, you continued your physical assessment. It
revealed that he has a protuberant abdomen and walks with a wide stance. He is still wearing his
diaper but according to the mother they already started potty training him. He sometimes has bed
wetting episodes but they understand that they do not need to punish him for that just like the
training they did with his brother Josh. He most often inform them if he needs to use the potty.
Labs were taken and to follow up results. Medications were ordered and started. Marty was placed
on I and O monitoring q hourly for 24 hours cc/cc then to shift to q 4 hours thereafter. You have
instructed the mother to keep the affected hand elevated and to call out if there are other concerns.
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Weight: 27.5 pounds

Height: 85. 8 centimeters
Head circumference: 41.6 centimeters
Chest circumference: 43 cms
Vital signs: T= 36.3 degrees Celsius, RR= 29cpm, HR= 98bpm, BP= 100/65
Medication:
MMR (1st dose) given on 13 months of age

Hepatitis B vaccine (3rd dose) given on 15months of age
Haemophilus Influenza type b (Hib) 3rd dose given on 15months
DTap vaccine (4th dose) given on 18months
Ascorbic acid (Ceelin) 5ml P.O, OD
Iron + Vitamin B Complex (Ferlin syrup) 1ml P.O daily
November 9, 2022
Vital signs:
BP: 100/60
PR: 96
RR: 20
Pain: 4/10
Seen by Dr. Lariosa at 10 am with orders and carried out.

Dressing was done by Wound Management Nurse
The affected area was clean and dry. Marty is calmer when talked to but cries when he feels pain.
He can be soothed easily compared yesterday upon admission. His IV site remained patent and
intact with an IV of D5 LR 1 liter with flowrate decreased to 100ml/hr at 10 am. According to the
mother he was able to void approximately around 80 ml according to the nurse who weighed his
diaper. He drinks a lot of water and milk with a total of 100 ml since 7 in the morning.
At 2 pm, the mother reported that Marty defecated once around 11 am. Had a total intake of 350
ml. He was able to void again twice and the mother said that it was around 120ml.
November 10, 2022
Vital signs:
BP: 95/60
PR: 96
RR: 21
Pain scale: 2/10
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Seen by Dr. Lariosa with orders and carried out. Advised to go home the next day with home
medication to be instructed.
Dressing was done by Wound management Nurse
The affected area remained dry and healing well. Marty was in a much better mood. Plays with his
mother and toys. The mother was telling you that she was glad that they came immediately in the
hospital. She said that she should learn more on how to keep her son safe. That with Marty’s age
anything can be expected.
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08/12/2020
November 8, 2022
November 8, 2022
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08/12/2020
November 9, 2022
November 8, 2022
November 10, 2022

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Laboratory Results
CBC AND SERUM ELECTROLYTES

November 8, 2022 @ 1pm
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November 8, 2022 @ 1pm
Urinalysis: November 8, 2022 @ 1 pm

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Chest X-ray: Normal Chest (November 8, 2022 5 pm)
What to Do?
To immerse yourself in the care management of your patient, let us do some detailed description
of your patient care tasks. Using the Case Scenario assigned to you, you are expected to perform
the following:
1. Fill-up the needed data based on the given scenario/case.

2. Conduct a history taking and physical assessment of your patient. Discuss the health
history of the patient narrative, in chronological order as much as possible. Use the DDC
Health Assessment form for documenting PA findings.
3. Discuss the developmental milestones of your patient in chronological order in terms of:
a. Physical Growth
b. Gross Motor Development
c. Fine Motor Development
d. Socialization/ Language
e. Play
f. Senses
g. Emotional Development
4. Interpret the therapeutics done for the patient: doctor’s orders, laboratory and diagnostic
tests done, and surgical procedures to be performed. Use format presented.
5. Present your drug study and IVF data. One drug study per student. Transcribe the IVF
and medications in the appropriate sheets.
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6. Formulate a patient-centered care plan for your patient. Integrate in your care
intervention significant bio ethical and legal standards of patient care. One NCP per
student.
7. Document the care given by making a nurse documentation following the FDAR format
(individual).
8. Clinical Reasoning Questions - Collaboration: Accidents are the major cause of
death in children of all ages. Accidental ingestions (poisoning) are the type of
accident that occurs most frequently in toddlers (Dart & Rumack, 2008). A young 2
year old girl was admitted in Pedia Ward due to fever and cough. She was playing
with her toys unsupervised by the mother. Upon the return of the mother from the
restroom, she noticed that her child was chewing something on her mouth and
noticed that the child went through her bag on top of the child’s bed. Concerned with
what her daughter was eating, she then rush to her assigned nurse and raised her
concern. What is your best action regarding this? Knowing that this is a safety concern, how
would you tell the staff nurse? Follow the CUS method.
C I am concerned about the child’s situation. The child is currently in the stage of
development wherein she is curious about anything and puts something in her
mouth. Without any supervision by the child’s mother, she puts something in her
mouth and chews it.
U Because the parent's role was not evaluated, I feel uncomfortable with them. The
responsibility of a parent is to provide the safety of their child. Their infant is 2
years old, in particular.
S This calls for a safety issue. The infant could suffer major injuries, problems, or
even death as a result of the parent's negligence. This is an issue that may be
avoided; the definition of a parent needs to be clarified.
9. Clinical Reasoning Questions - Ethico-Moral-Legal: During your morning shift you

were assigned to a 2 year old toddler. While doing your morning care and taking the VS of
your patient, you noticed while she was playing, she wet herself. You then talked calmly to
the child and informed the mother. The mother angrily approached the child and pulled the
child’s hand while reprimanding her for wetting the bed. The mother was slapping the leg of
the child while removing her clothes with force causing the patient to cry. What would be
your nursing action in this situation? What ethical principle is applicable in this scenario?
Justify?
Nursing Action Establish a therapeutic connection with the mom and patient while
demonstrating unwavering kindness and unending admiration for them.
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The most we can do for the patient is to alleviate his pain and treat his
burn as soon as possible to prevent infection. Ensure the patient receive
essential physical recovery. Additionally, provide health education and
report any significant finding.
Ethical Principle Accountability – For nursing care and other actions, nurses are
Upheld responsible. They must be prepared for the negative effects of their
actions may have on their careers and personal lives.
Fidelity – The nurse must deliver a high-quality, safe care in a well-
informed manner in order to uphold professional promises and
obligations.
Autonomy – When the nurse recognizes the patient as an individual
with the inherent right to have their own perspective, thoughts, beliefs,
and values, the self-determination is protected. Nurse’s support patient’s
autonomy by not passing judgment or giving pressure on them. All
treatments may be accepted or rejected by the patient.
Veracity – Being honest of the nurse to the patient; nurses should not
hide anything from patients, even if doing so can make them upset or
uncomfortable.
Have you answered all of the questions above? Great! You are now ready for to proceed
to the next part of the module.
Congratulations! You have completed this module. You may now proceed to the weekly quiz.
Please wait for further instructions from you instructor.
References:
Silbert-Flagg,J. & Pillitteri, A. (2018). Maternal & Child Health Nursing, Care of the childbearing &
Childrearing Family, 8th Edition. Wolter Kluwer Health
Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb’s fundamentals of nursing: Concepts,
process, and practice (10th ed.). Pearson Education, Inc.
Website:
https://www.cdc.gov/growthcharts/background.htm
https://www.doh.gov.ph/expanded-program-on-immunization
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COMPREHENSIVE HEALTH ASSESSMENT

Name of Patient: Marty John Age: 27-month-old Sex: M Civil Status: N/A
Impression/Diagnosis: 2nd degree burn
Date of Admission: November 8, 2022 Attending Physician: Dr. Lariosa
Date of Assessment: November 8, 2022 Room #: P302
I. HEALTH HISTORY
Chief Complaint:
Thermal injury
Present Health Status:

Patient M is a 27 month old toddler weighing 27.5 pounds. He was brought into the emergency
room due to a 2nd degree burn. His mother, Mrs. Lorraine left Marty alone playing on the sofa
while she was preparing lunch, she then went out to throw the garbage. Out of nowhere, she
heard Patient M’s painful cries. She then saw him near the frying pan. She stated that it seemed
like Patient M dipped his hand in the frying pan. During the physical examination, Patient M was
crying uncontrollably. His parents tried to calm him down by giving him a blanket but continued
to be irritated and crying out of pain and pointing towards his right hand. An IV was attached in
his left metacarpal vein. His eyes appear to be swollen and there’s no difficulty in breathing
during the assessment. The affected hand was seen to start blistering. Furthermore, redness is
noted around the area and the skin looks shiny. While continuing the assessment, it was noted
that Patient M walks with a wide stance and has a protuberant abdomen. His vital signs were BP
100/60mmHg, PR 96bpm, RR 20cpm. His pain scale was ranked 4 out of 10.
Past Health History:

Patient M was born at 1:33PM on August 12, 2020, weighing 6.3 pounds. He doesn’t have any
history of illness, but he does have a history of medications. At 13 months, he was given the 1st
dose of MMR vaccine. Then, at 15 months, he was given the third dose of Hepatitis B vaccine
and third dose of Influenza Type B vaccine. At 18 months, he was given the 4th dose of DTap
vaccine. He also takes vitamins, such as ascorbic acid (Ceelin) and Iron + Vitamin B Complex
(Feline Syrup). It was reported that he got his first tooth at 6 months. He sat up by himself and
started crawling around eight months and was walking around at 13 to 14 months. It was also
reported that one area Marty struggled with was going down the stairs, in which around 18
months, he fell down a couple of stairs.
Current Lifestyle:
Patient M is an active child. One of the recent activities that showcased his fine motor skills was
his throwing a ball overarm. He does things with both hands, but most of the time he shows signs
of being right handed. He can do the puzzles that require putting pieces into an indented board.
Patient M enjoys simple dances and rhythms especially when he hears music. He also eats very
well. He takes a one to two hours nap in the afternoon yet he's still able to sleep through the
night. He loves to play with water and he even learned how to put shampoo in his hair. Patient
M talks with words and gestures although the words aren’t clear especially when he is excited.
Psychosocial Status:
The mother stated that Patient M seems to be pretty open about his emotions. . When he is mad,
he screams. When he is hurt, he cries. When he has done something wrong and has gotten in
/DDCNSGFORMS/2020/HA/ECAJES.BNIEVE Comprehensive Health Assessment Form | Page 16 of 23

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trouble he simply looks down and gets sad. Also, the patient is said to be known as a tornado,
for being playful and energetic. It was reported that he enjoys being around people and has a
blast playing with his toys or with his family members and enjoys playing with everything from
anyone’s shoes to Little People toys. It was then reported that Marty throws tantrums when upset,
but only for a short period of time. It was also said that he shows empathy and exhibits a caring
attitude.
Family History:
There were no hereditary diseases mentioned on either the maternal or paternal sides.
Gynecologic History (if applicable):

Menstrual History (Usual Cycle) Interval: Duration: Amount of Menstrual Flow:
Last Menstrual Period and Expected Date of Delivery LMP: EDD:
History of Dysmenorrhea? [ ] Yes [ ] No
Gynecologic surgeries? [ ] No [ ] Yes (pls. specify)
Obstetric History (if applicable):

Pregnancy Profile (GTPAL) Gravity: Term: Preterm: Abortions: Living Children:
Previous Pregnancies? [ ] No [ ] Yes (Please specify in chronological order)
Date: Name of Child Type of Delivery Outcome
II. PHYSICAL EXAMINATION
A. PRELIMINARIES
VITAL SIGNS AND ANTHROPOMETRICMEASUREMENTS
Blood Pressure: 100/65 mmHg Height: 8.5 cm

Heart rate: 98 bpm Weight: 27.5 lbs
Pulse Rate: 98 bpm BMI: N/A
Temperature: 36.3 °C [ ] within ideal body weight (IBW)
Respiratory Rate: 29 cpm [ ] less than IBW
Others: N/A______________ [ ] more than IBW; specify:______________

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GENERAL SURVEY:
Marty John, a 27-month-old boy, was admitted due to a 2nd degree accidental burn
at his right hand. Upon physical assessment, Marty was crying uncontrollably and
his mother and father were calming him down. His eyes were already swollen. His
parents tried to give him blanket but he continued to be irritated and crying out of
pain, and pointing towards his right hand. The affected hand started to have blisters,
redness is noted around the area and looks shiny. Additionally, patient’s skin was
fair, soft, and warm to touch. No difficulty in breathing was noted but, his abdomen
is protuberant and walks with a wide stance. Aside from all that was mentioned,
there were no other unusualities noted in the extremities. Furthermore, Marty
weighted about 27.5 pounds, with a height of 85.8 centimeters. His head
circumference measured 41.6 centimeters, and his chest circumference measured
43 centimeters. His vital signs were as follows: temperature of 36.3 °C, respiration
rate of 29 cpm, heart rate of 98 bpm, and blood pressure of 100/65. He has an IV in
his left metacarpal vein, intact and patent with D5 LR 1 liter @ 112 ml/hour at a level
of 950ml.
B. INTEGUMENTARY SKIN
Color: Unaffected skin is fair; affected skin is red

Texture: Unaffected skin is smooth and warm to touch; affected skin has blisters and shininess
Turgor: N/A
Scaling: N/A
Hair Distribution: N/A
Hair Characteristics: N/A
Infestation: N/A
Comments: N/A
STOMA [/] not Applicable

[ ] clean dry [ ] redness [ ] chronic redness [ ] drainage [ ] chronic drainage
[ ] prolaps
Comments: N/A
FINGERNAILS & TOENAILS

[/] color, chare, cleanliness good [/] no problems or deviations assessed
[ ] irregularities in surface:
[ ] inflammation around nails:
[ ] fungal problem:
C. HEAD AND NECK
HEAD & NECK

Head Motion (describe):
[ ] asymmetric head position (describe):
[ ] shrugs shoulders [ ] unable to support head midline& erect [ ] dull, puffy, yellow skin

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[ ] peritoneal edema [ ] lymph node enlargement [ ] thyroid enlargement

[ ] tracheal displacement
Comments: No abnormalities found in assessing the head and neck.
NOSE & SINUSES

[ ] nasal drainage [ ] inflamed [ ] tender [ ] polyps/lesions [ ] edema
[ ] altered nasal mucosa (describe):
[ ] absence of frontal sinus glow [ ] right nostril occluded [ ] left nostril occluded
Comments: No abnormalities noted.
MOUTH & PHARYNX

[ ] altered oral mucous membrane (describe): N/A
[ ] Inflammation (describe): N/A
[ ] hoarseness [ ] bruxism (grinds teeth) [ ] loose teeth [ ] decay [ ] halitosis
[ ] excessive salivation [] lips dry, cracked [ ] lip fissures [ ] lip bleeding
[ ] gums inflamed [ ] gums bleed [ ] gum retraction [ ] thick tongue [ ] tongue dry, cracked
[ ] tongue fissures [ ] tongue bleeds
Inspected the following:

[ ] Inner oral mucosa [ ] buccal mucosa [ ] floor of mouth and tongue [ ] hard palate [ ] soft palate
Deviations (describe): N/A
[ ] lesions, vesicles (describe): N/A
[ ] gag reflex absent [ ] gag reflex hyperactive [ ] poor denture fit or not using
[ ] chewing problem [/] missing teeth
Comments: Pt only has 20 teeth due to young age.
D. EYES AND EARS
EYES
Visual Acuity: N/A
Visual Fields/Peripheral: N/A
Eye Tracking Present: [ ] up [ ] down [ ] right [ ] left [ ] corneal light reflex aligned [ ] light
reflex misaligned [ ] nystagmus
External Eye Structure:

Abnormalities (specify/describe): N/A
Blink Reflex: N/A
Pupil & Iris Direct Light Response: N/A
Pupil & Iris Consensual Light Response: N/A
Ophthalmoscopic Exam: N/A
Unable to do ophthalmoscope exam due to: N/A
Comments: Swollen eyes due to crying.
EARS
External Ear Structure: N/A
External Ear Structure Abnormalities: N/A

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Other Abnormalities (describe): N/A

Otoscopic Exam:
[ ] cone of light visualized [ ] cone of light not visualized [ ] tympanic membrane inspected
[ ] excessive cerumen [/] Unable to examine [ ] Simple hearing acuity test:
Comments: All assessment in the ears is normal, no abnormalities found.
E. CARDIOPULMONARY
HEART & VASCULAR

Auscultated Heart Sounds: N/A
Apical Pulse (rate & rhythm): N/A
Jugular Venous Distention: [] present [] absent capillary refill: [/] > 1 second [] < 2 seconds
[ ] PMI palpable – 5th intercostal space medial to left midclavicular line [ ] PMI not palpable
[ ] edema (describe): N/A
Blood Pressure: 100/65 mmHg MAP: N/A [ ] Pulse Deficit: N/A
Peripheral Pulses: 98
Comments: Vital signs within the normal range.
THORAX & LUNGS

Inspected: [ ] posterior thorax [ ] lateral thorax [ ] anterior thorax
Thorax deviations: [ ] scoliosis [ ] lordosis [ ] barrel chest [ ] intercostal bulging
[ ] Others: N/A
Auscultated breath sounds: [ ] vesicular sounds at periphery
[ ] bronchovesicular sounds between scapulae or 1st – 2nd intercoastal space lateral to sternum
[ ] bronchial sounds over trachea
Adventitious sounds: [ ] wheezes [ ] crackles [ ] rhonchi Location: N/A
[ ] clear with cough [ ] Other: N/A
Respiratory Distress: [ ] nasal flaring [ ] use of accessory muscles, specify:
[ ] SOB [ ] Intercoastal retraction Respiratory Rate: 29 cpm Oxygen Saturation: N/A
[ ] apnea
Comments: No difficulty in breathing upon assessment.
F. GASTROINTESTINAL
ABDOMEN
Bowel Sounds: [ ] Present in all quadrants, counts per minute:
[ ] absent [ ] hypoactive [ ] hyperactive [ ] tympanic
Abdomen: [ ] flat [ ] distended [ ] soft [ ] firm [/] rounded [ ] obese [ ] asymmetry
[ ] pain [ ] rebound tenderness [ ] umbilical hernia
[ ] Others: N/A
[ ] gastrostomy [ ] jejunostomy [ ] large intestine transverse ostomy
[ ] large intestine sigmoid ostomy [ ] mass: N/A
Abdominal Skin Characteristics: N/A
Comments: Protuberant abdomen

Nursing Program
G. GENITOURINARY (GYNECOLOGICAL & BREASTS)
BREASTS
Deviations assessed in: [ ] size [ ] symmetrical [ ] contour [ ] shape [ ] skin color [ ] texture
[ ] venous pattern
Nipple Deviations: [ ] retraction [ ] discharge [ ] bleeding [ ] nodules [ ] edema [ ] ulcerations
Breast Self-Exam (if applicable): [ ] independent [ ] needs instructions to complete
[ ] unable to complete
Comments:
GENITO-URINARY & GYNECOLOGIC

External genitalia inspected: [ ] excoriations [ ] rash [ ] lesions [ ] vesicles [ ] inflammation
[ ] bright red color [ ] swelling [ ] bulging [ ] discharge [ ] inguinal hernia [ ] tight scrotal skin
[ ] large scrotum [ ] phimosis [ ] displaced meatus
Testicular Self-Exam (if applicable): [ ] independent [ ] needs instructions to complete
[ ] unable to complete
Comments:
OBSTETRIC ASSESSMENT (IF APPLICABLE)
Estimated Fundal Height: Estimated AOG (based on FH measurement):

Age of Gestation (AOG):
Fetal Presentation & Attitude: Fetal Line: Fetal Position:
O Cephalic O Longitudinal O Occiput posterior O LOA
[ ] Vertex [ ] Sinciput [ ] Brow [ ] Face [ ] Chin O Transverse O Occiput anterior O LOT
O Shoulder O Oblique O ROP O LOP
[ ] Complete [ ] Footling [] Frank O ROT
O Breech O ROA
[ ] Arm [ ] Shoulder [ ] Trunk
O Compound; specify:
Uterine Contraction: Fetal Station and Engagement:
Strength [ ] -3
O Mild [ ] -2
O Moderate [ ] -1
O Severe []0
Duration: [ ] +1
Interval: [ ] +2
Frequency: [ ] +2
Comments:
H. MUSCULOSKELETAL
[ ] Gait abnormalities: N/A

[ ] Posture abnormalities: N/A
[ ] Impaired weight bearing stance: N/A
[ ] Bilateral symmetry: N/A

Nursing Program
[ ] Asymmetry: N/A
[ ] Bilateral alignment: N/A
[ ] Misalignment: N/A
[ ] Decreased ROM: N/A
[ ] Joint swelling [ ] stiffness [ ] tenderness [/] Heat: Patient is warm to touch.
[ ] Hypertonicity: N/A
[ ] Hypotonicity: N/A
Comments: No unusualities in the extremities; walks in a wide stance.
I. NEUROLOGIC SYSTEM
MENTAL & EMOTIONAL STATUS

[/] alert [ ] aware of environment [ ] impaired consciousness
GCS score: N/A RLS score: N/A
[ ] changed level of consciousness [ ] unchanged level of consciousness [ ] able to communicate
[/] vocalizes sounds [ ] limited verbalization [ ] non-verbal
[ ] change in communication pattern [ ] unchanged communication
Communication Device: N/A
[ ] intellectual impairment unchanged [ ] memory impairment unchanged
[ ] general knowledge deficit unchanged [ ] abstract reasoning unchanged
[ ] impaired association ability unchanged [ ] impaired judgment unchanged
[/] changes in mental & emotional status (describe): Irritable and crying uncontrollably.
Comments: N/A
CRANIAL NERVE (CN) FUNCTION

CN I – olfactory [/] intact [ ] impaired [ ] unknown
CN's II-III-IV-V – optic, oculomotor, trochlear, abducens (see eye exam)
CN VI – trigeminal (facial sensory & jaw motor) [/] intact [ ] impaired
CN VII – Facial (symmetry in face expressions & taste) [/] intact [ ] impaired
CN VIII – Acoustic (see hearing exam) [/] intact [ ] impaired
CN IX – Glossopharyngeal (taste at back of tongue) [/] intact [ ] impaired
CN X – Vagus (palate movement, "ah" and vocal motor [/] intact [ ] impaired
CN XI – Spinal Accessory (head motion & shrug) [/] intact [ ] impaired
CN XII – Hypoglossal (tongue position & motor) [/] intact [ ] impaired
SENSORY FUNCTION
Touch [/] intact [ ] impaired (describe): N/A
Pain [/] intact [ ] impaired (describe): Able to feel pain by pointing to affected area along
with crying.
MOTOR FUNCTION
[ ] impaired coordination [ ] fine motor skills impaired
[/] balance maintained while standing with eyes closed [ ] loss of balance immediate
REFLEXES
Patellar Reflex:
[ ] 0: no response

Nursing Program
[ ] 1+ low (normal with slight contraction)

[/] 2+ normal, visible muscle twitch and extension of lower leg
[ ] 3+ brisker than normal
[ ] 4+ hyperactive, very brisk
SUMMARY OF SIGNIFICANT FINDINGS (Narrative):
Marty John, a 27-month-old boy, was admitted on November 8, 2022 @ 8AM due to a 2nd degree
burn at his right hand. Upon physical assessment, Marty was crying uncontrollably and his mother
and father were calming him down. Upon interview with the mother she verbalized “Wala gyud ko
ngdahum nga musaka na diay na sya ug iyaha bah, lihukan pud lagi bataa oi. Naluoy jud ko
pagkakita nko sa iyaha nga pirti niyang tiyabaw mao gidala nako dayun sya sa ospital.” When
asked what she did before going to the hospital, she said that she just placed the hand over the
running water, cleaned the burned area. Marty now weighs 27.5 pounds. Height is 85. 8
centimeters, his head circumference is 41.6 centimeters, chest circumference is 43 cm. When
checking his vital signs, his results where T= 36.3 degrees Celsius, RR= 29cpm, HR= 98bpm, BP:
100/65. There seems to be no difficulty in breathing upon assessment. His eyes are normal, pupils
equally round and reactive to light. His eyes were already swollen. When the mother was asked
how many teeth Marty has she said that she counted recently and noticed he has around 20 teeth
total. No other unusualities were noted at the mouth. His skin is fair, soft and warm to touch. The
affected hand started to have blisters, redness is noted around the area and looks shiny. Aside
from that there were no other unusualities in the extremities. It revealed that he has a protuberant
abdomen and walks with a wide stance.
Nursing Diagnosis:
1. Impaired comfort r/t pain as evidenced by pt's 2nd degree burn.
2. Impaired skin integrity r/t damage to the skin and surrounding tissues secondary to 2nd
degree burn injury.
3. Acute pain rt destruction of skin tissues on the burned are Secondary to 2nd-degree burn.
Assessment done by:
Keithly Jjhoy C. Macalos

Signature over Printed Name of Student
III. FOCUSED PHYSICAL ASSESSMENT [Should be completed on the 2nd and 3rd day]
System Assessed: [/] Integument [ ] Head & Neck [/] Eyes & Ears
[/] Cardiopulmonary [/] Preliminaries [/] Gastrointestinal [ ] Genitourinary/OB
[/] Musculoskeletal [/] Neurologic Inspection
Inspection
On November 8 2022, patient was noted to have swollen eyes due to crying. Patient did
not seem to have trouble breathing. Patient also has 20 teeth at his current age. His skin was
noted to be fair, smooth and warm to touch in his affected area. In his affected arm, blisters started
to form, redness and shininess was noted. He was also noted to have protuberant abdomen and
walks with a wide stance.

Nursing Program
Palpation
N/A
Percussion
N/A
Auscultation
N/A
Other significant findings:

On November 9 2022, vital signs are checked and recorded, the following results are : HR
– 96 bpm, RR – 20 CPM, BP – 100/65 mmHg.. Weight is 27.5 lbs and height is 85.8 cm. Head
circumference is noted to be 41.6 cm while chest circumference at 43 cm. On November 10 2022,
vital signs were checked and recorded with the results of: BP - 95/60 mmHg, PR - 96 bpm, RR -
21 cpm, and pain scale at 2/10.
Assessment done by:
Keithly Jjhoy C. Macalos

Signature over Printed Name of Student

Nursing Program
DEVELOPMENTAL MILESTONES
Gross Fine
Emotional
Age in Physical Motor Motor Socialization
Play Senses Developme-
Months Growth Develop- Develop- /Language
nt
ment ment
First
6 - - - - - -
tooth
Sat up by
Babbled loudly
himself
as an infant
and
8 - - and his first - - -
started
word was
crawling
“Dad”.
around.
Started
13 - - - - - -
walking
Started
14 - - - - - -
walking
Crawl Repeats what Enjoys simple He fell down a
down his mom says; dances and couple of
stairs has recently rhythms stairs but is
18 - backwards - started to eat - especially scared so he
and fell. at the dinner when he scoots his
table on a seat hears music. bottom down
with family. the stairs.
Learned Talks with He bonds with
how to put words and mom by playing a
objects in gestures; ball that has
and out of words are not different cut out
container; clear when he shapes on it; he
he knows is excited; loves to play in
how to learned the the water, and
24 - - - -
dress word “no”; how to put
himself imitate other shampoo in his
with a especially his hair and make a
simple brother Josh. bubble drop and
shirt splashes the room
without a with a lot of
button. water.
Weighed Started to Throwing Has started to Pick up his toys if Whenever he
27.5 climb the a ball put together instructed; if is upset he
pounds stairs; overarm in two or three asked to pick up shows
27 climb even short word his trash, like a - tantrums and
up to their distances; sentences; “I wrapper, he will go through
stove. stretching out” “love you” throw it to the different
out arms “hot, hot” and trash bin. moods within
Nursing Program
to catch; “I am Marty” a short period

rolling the are some of time.
ball using words.
the arms;
kicking it.

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Davao Doctors College, Inc.

College of Allied Health Sciences

NRG 203: CARE OF MOTHER, CHILD AND ADOLESCENT

Getting to Know the Course Instructor

Contact No: (per request)

Introduction to the Course

Course Number: NRG 203

Course Credits 9 units (4 units Lecture, 5 units RLE)

No of Hours (Lab): (20 hours/week for 18 weeks)

Placement: Second year, First Semester

Prerequisite: NRG 105, NRG 106

Schedule: MTWThFS 7am-1pm; 1pm-7pm

Requirements in Completing the RLE Activities

1. Microsoft Office/Google Docs

Access to a printer and/or scanner is also a plus, but not a requirement.

Day 1 (Monday/Thursday) Day 2 (Tuesday/Friday) Day 3 (Wednesday/Saturday)

Completion of Module, to be Receiving of Handover Case Presentation (cont.)

Term: First Semester S.Y. 2022-2023

Case Scenario: Second Degree Accidental burn at Right Hand

Course in the Ward

Weight: 27.5 pounds

MMR (1st dose) given on 13 months of age

Seen by Dr. Lariosa at 10 am with orders and carried out.

November 10, 2022

November 10, 2022

CBC AND SERUM ELECTROLYTES

November 8, 2022 @ 1pm

Urinalysis: November 8, 2022 @ 1 pm

Chest X-ray: Normal Chest (November 8, 2022 5 pm)

1. Fill-up the needed data based on the given scenario/case.

9. Clinical Reasoning Questions - Ethico-Moral-Legal: During your morning shift you

COMPREHENSIVE HEALTH ASSESSMENT

Present Health Status:

Past Health History:

/DDCNSGFORMS/2020/HA/ECAJES.BNIEVE Comprehensive Health Assessment Form | Page 16 of 23

Gynecologic History (if applicable):

Obstetric History (if applicable):

Date: Name of Child Type of Delivery Outcome

II. PHYSICAL EXAMINATION

VITAL SIGNS AND ANTHROPOMETRICMEASUREMENTS

Blood Pressure: 100/65 mmHg Height: 8.5 cm

/DDCNSGFORMS/2020/HA/ECAJES.BNIEVE Comprehensive Health Assessment Form | Page 17 of 23

Color: Unaffected skin is fair; affected skin is red

STOMA [/] not Applicable

FINGERNAILS & TOENAILS

C. HEAD AND NECK

HEAD & NECK

/DDCNSGFORMS/2020/HA/ECAJES.BNIEVE Comprehensive Health Assessment Form | Page 18 of 23

[ ] peritoneal edema [ ] lymph node enlargement [ ] thyroid enlargement

Comments: No abnormalities found in assessing the head and neck.

NOSE & SINUSES

Comments: No abnormalities noted.

MOUTH & PHARYNX

Inspected the following:

Comments: Pt only has 20 teeth due to young age.

D. EYES AND EARS

External Eye Structure:

/DDCNSGFORMS/2020/HA/ECAJES.BNIEVE Comprehensive Health Assessment Form | Page 19 of 23

Other Abnormalities (describe): N/A

Comments: All assessment in the ears is normal, no abnormalities found.

HEART & VASCULAR

Comments: Vital signs within the normal range.

THORAX & LUNGS