infant person
TRANSCRIPT
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: $oman Cat%olic
Father: Fer&inan& Templanza Age : 4' years ol&
Educational Attainment: Colle#e level Occupation: Tec%nician
Mother: (elen Templanza Age: ') years ol&
Educational Attainment: Colle#e level Occupation: Travel *#ent
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+$*. /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$oid %accines were not yet
gi%en& Right now! the infant is gi%en %itamins y his mother like /eelin&
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Immunization Table
0C+ Feruary 3! ,-.- - -
DPT March ,3! ,-.- April ,.! ,-.- May .6! ,-.-/P1 March ,3! ,-.- April ,.! ,-.- May .6! ,-.-
(epa 0 Feruary ,! ,-.- March ,3! ,-.- April ,.! ,-.-
* utrition
#he ay only had one week of reastfeeding from the mother! with a feeding fre1uency
of e%ery 9 hours& #he shortness of time of reastfeeding was due to the strong sucking aility ofthe ay and also since she is a working mother and has no time to reastfeed the ay as
%erali2ed y the mother& n order to suffice the needs of the ay! the mother had to ottle"feed
the ay with 4romil! a formula milk which is dissol%ed in .;- cc for 9 scoops& For the solid food
preferences of the ay! the mother gi%es /erelac& For the %itamins and food supplements of
the ay! the mother gi%es 4olyiflor! Ferlin! and /eelin& For now! the ay still has no any tooth
ut the client has good appetite as %erali2ed y the parents as e%idenced y the client wanting
for more& #he client always eats /erelac as food 9"0 times a day&
0 limination
E%ery day! the client defecates on his diaper one to two times a day& #he infant(s stool
has form with pale yellow coloration since he is ottle fed already& As what the client(s father
had said! the infant(s stool can almost fill up a regular drinking glass& For the infant(s urination!
the parents do not know the amount of urine the ay urinates ecause it is in the diaper and is
hard to estimate& What they told the e$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&
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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
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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
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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&