MANILA DOCTORS COLLEGE President Diosdado Macapagal Boulevard, Metropolitan Park, Pasay City HEALTH CARE: RELATED LEARNING

EXPERIENCE NURSING PROCESS I. A. ASSESSMENT General Data Patients Initials: A. S. G Informant: R. F. P. ( Caregiver ) Address: Makati City Age: 2 years and 5 months and 9 days Sex: Female Date of birth: 03/15/2008 Civil Status: Child Occupation: N/A B. Chief Complaint N/A C. History of Present Illness N/A D. Past History Childhood Illness: None Adult Illness: None Immunization: BCG, DPT, Measles, Hepatitis B, Polio, OPV Adult Immunization: None Previous Hospitalization: None Operations: None Injuries: None Medications taken prior to going to the hospital: None Allergies: No known allergies E. System Review Not applicable for 3 years below. F. Family Assessment

Initials

Relationsh ip

Age

Sex

Occupatio Education n al Attainmen t Food Server College Graduate

E.J.G.

Father

33

Male

M.G.

Mother

31

Female

Travel agency supervisor

College Graduate

G.

Heredo-Family Assessment

Maternal: Hypertension Paternal: Hypertension and Diabetes H. Developmental History

Theorist Erik Erikson -Theory of psychosocial development.

Age 2yrs 5months

Task andAutonomy vs. shame & doubt

Patients Description The patient is shy when she enters the room, especially when she sees unfamiliar faces. But after 2hrs of building rapport to the child she was able to play with us, and she followed our instructions with limitations due to the activity that has been given to her. Anna has difficulty for toilet training because she always uses diapers for bowel elimination. And she was afraid of sitting on the toilet bowl, thinking that she might fall. Ann is selfcentered when it comes to her toys, sometimes she doesnt share her toys to her cousins. Anna knows how to obey her parents, because

Sigmund Freud -Theory of psychosexual development

2yrs 5months

andAnal phase

Jean Piaget -Cognitive development theory

2yrs 5months

andPre-conceptual phase

Lawrence Kohlberg -Moral

2yrs 5months

andPunishmentobedience

development theory

her parents will punish her like frightening the child using scary objects (cockroaches, rats, dolls).

I.

Physical Examination: Height: 79 inches Actual Height: 82 inches Actual Weight: 25 kg

Anthropometric measurements: Head: 14cm Chest: 25cm Abdomen: 18cm Vital Signs: Temperature: 36. 5C RR: 29/m BP: Not taken PR: 89bpm A. Skin The skin is light brown in color. Uniform in color except for the area exposed from the sun. No presence of edema, no lesions, and no masses. Presence of birthmark in the right face of the client. Moisture in skin folds and the axillae. The temperature of the client is warm to touch. The skin is intact. B. Nails Convex curvature of the nail plate. Smooth to touch, Light pink color of the nail beds. Intact epidermis. High capillary refill. C. Head & Face Normpcephalic of the head. Rounded shape and smooth skull contour. Absence of masses and nodules. Symmetric facial features. No presence of edema. Symmetric facial movements. D. Eyes The eyebrows is evenly distributed. The skin is intact. Eyebrows are symmetrically aligned and equal in movement. The eyelids closes symmetrically. No discharge and no colorations. Bilateral blinks. When eyelids open, no visible sclera above cornea. The bulbar conjunctiva is transparent in color. Palpebral conjunctiva is shinny and smooth. No edema in the lacrimal glands. Illuminated pupil

constrict. Pupils constrict when the object is near and dilate when it is far. E. Ears The color of the ear is same with the color of the face. Auricle aligned with the outer cantus of the eyes. The auricle is mobile and firm. Pinna recoils after it is folded. Dry cerumen. Pearly gray color of the tymphanic membrane. Tuning fork is not tested. Both ears can hear clearly. F. Nose Symmetric nose. No presence of discharge and uniform in color. No tenderness and no lesions. Air moves freely in the nares. The mucosa is light pink in color. Nasal seotum is intact and in the middle line. No tenderness in the maxillary and frontal sinuses. G. Mouth & Pharynx Internal structures of his mouth are pinkish in color. Lips are brown to pink in color, dry and is symmetrical, Tonsils are pinkish to reddish in color with no swelling, Teeth are yellowish in color. 24 teeth. The tongue is at the center position. Tongue can move freely. Tonsils show no signs of inflammation, Absence of swelling. Absence of tenderness, Gag reflex not tested. H. Neck The muscles of the neck is equal in size and head centered. Smooth movements without discomforts. The lymph nodes are not palpable. Glands ascends during swallowing but not visible. Absemce of bruish sound. I. Thorax & Lungs Spine is vertically aligned. Spinal column is straight , right and left shoulders and the hips are at the same height. Chest wall are intact. No tenderness and no masses. Full and symmetrical chest expansion. Percussion did not apply, because the client is sensitive and she s crying. Vesicular and bronchovesicular breathe sounds. Quite and effortless respirations. J. Cardiovascular/Heart No pulsations on the aortic, pulmonary, tricuspid area. Symmetric pulse volumes and full pulsation. No sound heard in the carotid artery. Jugular veins are not visible. K. Breast and Axillae Skin uniform in color. The areola is round in shape and light brown in color. The nipples are rounded in shape and equal in size. No discharge presence. No tenderness and no masses. L. Abdomen

Unblemished skin. Uniform in color of the abdomen. It is rounded and flat. No evidence of enlargement of the liver and spleen. Symmetric contour. Visible peristalsis. No visible vascular pattern. Audible bowel sounds. Absence of friction rub and arterial bruits. No tenderness and smooth abdomen. The liver is not palpated. The pubic symphysis is not palpable. M. Extremities The arms and legs are uniform in color. Symmetrically aligned and no deformities. The client can move her arms freely without discomforts. No swelling and no tenderness. Muscles are equal in both sides of the body. No contractures. Normally firms. N. Genitals No presence of pubic hair because of her age. Pubic skin is intact. No lesions. Urethral orifice as a small slit and is the same color. No enlargements and tenderness of the lymph nodes. O. Rectum & Anus The perianal skin is intact. Anal skin is more pigmented, coarser and moister than perianal skin. Anal sphincter has a good tone. No presence of hemorrhoids . P. Neurologic Exam Based on the Metro- Manila Developmental Screening Test, the client can do simple task like kicking the ball, making a 2 tower of blocks, writing some vertical line. She can able to follow simple instructions. She is a very shy type person. II. PERSONAL HISTORY

Habit: Vices: Lifestyle:

Sucking reflex none

Rank in the family: 3rd baby

Travel: None She is sleeping all the time, because she is still an infant. When she is hungry and when she has a fecal elimination, thats the only time she will wake up; she usually wakes up by crying because thats the only thing she can do to seek our attention.

Social Affiliation: None Clients usual day like: None III. ENVIRONMENTAL HISTORY

The internal environment of the client is clean and neat. She have an adequate space for playing her toys. No presence of vectors. The house is

quite and peaceful. The ventilation of the light is adequate and the water is well sustained. The water that she drinks is well sanitized. We have a screen in the house. The external environment is slightly noisy because of the neighborhood but they are not harmful because they cant hear the noise inside their house.. And there is a presence of vectors like cockroaches and rats anywhere. There are everyday garbage collection. When it is raining there are presence of mosquito everywhere. And they are experiencing flood in their streets.