infant person

8/13/2019 Infant Person

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Personal Data

Name of client: Kerby Templanza

Address: 292 Interior 4-D Ponce Street, Davao City

Birthday: February 2, 2! Ordinal Rank: 2 o" 2 siblin#s

Nationality: Filipino Religion: $oman Cat%olic

Father: Fer&inan& Templanza Age : 4' years ol&

Educational Attainment: Colle#e level Occupation: Tec%nician

Mother: (elen Templanza Age: ') years ol&

Educational Attainment: Colle#e level Occupation: Travel *#ent



+$*. /0S$1*TI/

* 3aternal/bstetricsPre-natal (istory

When the mother was pregnant with her ay! she had completed her pre"natal check"

ups as well as her #etanus #o$oid %accines& #he mother had two hours of laor and used

anesthesia in gi%ing irth to the infant& #he ay was then orn through normal spontaneous

%aginal deli%ery& 'uring pregnancy! the infant(s mother e$perienced 'iaetes or termed as

)estational 'iaetes Mellitus& #his is %ery common to pregnant women& *he also had increase

lood pressure as one of the signs of the said disease& +a%ing this complication! the mother

took medicines against hypertension and insulin& #herefore! the infant(s mother has a gra%ida of

,! para of ,! term of ,! pre"term of -! aortion of - and li%ing of ,&

0 0irt% (istory

#he mother of the client ga%e irth last Feruary ,! ,-.- in a hospital& *he had normal

spontaneous %aginal deli%ery of her second ay at *outhern Mindanao Medical /enter!

formerly 'a%ao Medical /enter& When the ay came out its weight was 0&, kilograms&

C eonatal (istory

After the eing orn! the client stayed in the nursery for three days& After three days! he

stayed eside his mother for si$ days ha%ing a total of nine days stay at the hospital& #hen child

underwent neworn screening on the same day that he was orn& Right after the ay was

orn! it took 1uite some time efore the ay was ale to cry& Regarding the medications that

was gi%en to the infant! the mother %erali2ed that the ay recei%ed a shot of something she

can(t rememer&

D In"ancy an& C%il&%oo& (istory

#he ay ne%er had childhood diseases like mumps! chicken po$! polio! measles!

pneumonia! hepatitis! asthma! nor diphtheria! ut cough& +e was hospitali2ed one time due to

cough which was treated with *alutamol& #he infant was then admitted to /+/'/& +e has no

any allergies and congenital prolems as %erali2ed y his mother& For his immuni2ations! he

had his B/) shot through intradermal route last Feruary 3! ,-.-& +is '4#! which was gi%en in

an intramuscular route and O45 which was gi%en through oral route! was gi%en on the same

days: March ,3! ,-.- followed y April ,.! ,-.-! then May .6! ,-.-& For his +epa B shot! it

was gi%en to him through intradermal route on the following dates: Feruary ,! ,-.-7 March ,3!

,-.- and April ,.! ,-.-& #he infant was not yet gi%en %accines for Measles since he is 8ust si$

months at the moment& Also! his +iB! Meningitis and #etanus to$oid %accines were not yet

gi%en& Right now! the infant is gi%en %itamins y his mother like /eelin&



Immunization Table

0C+ Feruary 3! ,-.- - -

DPT March ,3! ,-.- April ,.! ,-.- May .6! ,-.-/P1 March ,3! ,-.- April ,.! ,-.- May .6! ,-.-

(epa 0 Feruary ,! ,-.- March ,3! ,-.- April ,.! ,-.-

* utrition

#he ay only had one week of reastfeeding from the mother! with a feeding fre1uency

of e%ery 9 hours& #he shortness of time of reastfeeding was due to the strong sucking aility ofthe ay and also since she is a working mother and has no time to reastfeed the ay as

%erali2ed y the mother& n order to suffice the needs of the ay! the mother had to ottle"feed

the ay with 4romil! a formula milk which is dissol%ed in .;- cc for 9 scoops& For the solid food

preferences of the ay! the mother gi%es /erelac& For the %itamins and food supplements of

the ay! the mother gi%es 4olyiflor! Ferlin! and /eelin& For now! the ay still has no any tooth

ut the client has good appetite as %erali2ed y the parents as e%idenced y the client wanting

for more& #he client always eats /erelac as food 9"0 times a day&

0 limination

E%ery day! the client defecates on his diaper one to two times a day& #he infant(s stool

has form with pale yellow coloration since he is ottle fed already& As what the client(s father

had said! the infant(s stool can almost fill up a regular drinking glass& For the infant(s urination!

the parents do not know the amount of urine the ay urinates ecause it is in the diaper and is

hard to estimate& What they told the e$aminers was the ay changes diapers three to four

times a day ecause of its %oiding&

C *ctivity an& Sleep

#he ay usually sleeps at around se%en to nine o(clock at night and wakes up at

around <"= o(clock in the morning! so the ay sleeps aout 6"., hours a day& *ince the client

is still an infant! short intermittent sleep is e$pected of him& n taking naps! the ay takes naps

ut only for awhile! as %erali2ed y the mother& For the usual daily acti%ities of the ay! he

wakes up! eats! and plays! and when he gets tired! he takes a nap& #he ay usually sleeps in a

prone position while thum sucking& #he e$aminers asked the mother of the client if she plays

games with her son& *he told the e$aminers that she plays with the ay whene%er she gets the

chance to& One of the infant(s plays is the peek"a"oo& Also! the ay has toys which include

rattle and pillows& When one of the e$aminers got the chance to get a sneak peek inside their

house! there was a moile hanging on top of the cri of the ay&



D +ro5t% an& Development

• P%ysical Development

*nt%ropometric 3easurements

#he client(s anthropometric measurement was taken y the e$aminers as part of the

data gathering& For the infant(s height! he is =; centimeters& +e has a weight of nine kilograms&

+e has a head circumference of forty fi%e centimeters! a chest circumference of forty nine

centimeters and an adominal circumference of fifty centimeters&

Cep%alocau&al *ppearance

• (ea&

+ead is normocephalic& 4osterior fontanel has already closed ut the

anterior fontanel is still in the process of closing& #here were no lesions or any

manifestations noted& +air is lack and e%enly distriuted&

• yes

/ornea is transparent! shiny! and smooth7 details of the iris are %isile&

Eyes are e1ual in si2e and shape& #here were no discharges noted& Eyerows

are e%enly distriuted&

• ars

Ears are e1ual in si2e and color& #here were no discharges noted& #ips of

oth ears are in line with outer canthus of the eyes&

• ose

E$ternal nose is symmetric and straight& Nasal septum intact and is

midline& #he mucosa is pink& No flaring of nostrils as the clinet reathes through

the nares&

• ec6

*kin color of the neck is in uniform with the other skin areas of the ody&

• S6in

>niformity in skin color is noted& *kin is fair and smooth with no lesions or

infestations&

• ails



Nails are pinkish in color and well"trimmed&

• *no#enital

Anus is not imperforated and genital is not swollen! with no discharges

and has skin color uniformity! as %erali2ed y the mother&

• 7tremities

>pper e$tremities are proportional with the height! weight! and age of the

infant! as well as the lower e$tremities& #he musculoskeletal system is not yet

fully de%eloped&

Personal (y#iene

*ince the client is 8ust a ay! his mother is the one who pro%ides him proper

hygiene at this point& From the inter%iew! the mother tells us that the ay is athed

e%eryday at nine o(clock in the morning& #he water used for athing the ay is tap

water and is oiled afterwards& #he client uses ?ohnson(s *oap and *hampoo for

Baies& #he mother also changes the client(s clothes twice a day especially if it is

wet or spoiled already and applies @mansanilya to pre%ent colic! as %erali2ed y the

father& #here are also times that the mother puts powder on the ay(s ody

especially on the ack and groin& *he says that it is done to pre%ent rashes&

$e"le7es

• 0lin6in# $e"le7

nfant links spontaneously especially when strong light is shone or any

o8ect coming near the eye& #his refle$ persists throughout life&

• $ootin# $e"le7

#ouching or stroking cheek alongside of mouth causes infant to turn

head toward that side and egin to suck&

• Suc6in# $e"le7

*ucking is still noted as e%idenced y infant sucking from the feeding

ottle& #he mother gi%es the infant pacifier! as %erali2ed y her&

• Cou#% $e"le7

rritation of mucous memranes of laryn$ causes coughing& #his refle$

persists throughout life&

• S5allo5in# $e"le7



nfant already swallows some solid foods like /erelac since anything

that is placed at the ack of the tongue will e swallowed&

• Palmar +rasp $e"le7

#his refle$ should ha%e een disappeared y the age of = weeks to 9

months& 'uring our assessment in MM'*#! the infant grasped the cheese

curls in a raking motion using his whole right hand&

• Plantar +rasp $e"le7

When we touched the sole of the foot of the infant! the toes fle$ed&

• 0abins6i $e"le7

*troking outer sole of foot upward from heel and across all of foot

causes toes to hypere$tend and hallu$ to dorsifle$&

.an#ua#e Development

.an#ua#eDialects

n their household! the mother reported that they use 5isayan and#agalog as their ma8or language& With this the ay was ale to adopt some of

the words ut not yet fully pronounce it well&

8or&s ttere&

#he ay can now utter words such as @ mama @ and @ dada & #he

client has an older sister whom he calls @ te @ at the moment&

infant person

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