Clients Initals: G.C.
Age: 20 Days
Hospital Day: 7/11/12
Diagnosis: Pneumonia Immunization: Hep B, Polio, DTap Vital Signs: Bp 91/54 152 54 97.6
Neuro: Alert and awake. Strong Cry. Anterior Fontanels are soft and flat. Pupils are equal and reactive.
Respiratory: Regular breathing rate. Clear sounds with auscultations. Respiratory effort is easy.
Cardio: Regular heart rate. Clear sounds are strong. Capillary refill is brisk. Color of patient is pink.
Skin: Dry,warm and intact. I.V. site is intact of 5% Dextrose and 0.45% sodium chloride at a rate of 10ml/hr. No redness is noted at I.V. site.
Gu: Patient is bottle fed. Abdomen is soft and nontender. Active bowel sounds X4 quaderants.
GI: Continet. Last patient voided in diaper with a weight of 70ml.
TextBook Develpomental Norms:
Physical Assessment for a Newborn to 2 months old:
An infant's physical development infant begins at the head, then moves to other parts of the body (for example, sucking comes before sitting, which comes before walking). From Newborns to 2 month old children they are able to develop how to lift and turn the head when lying on his or her back, hands are fisted, the arms are flexed, neck is unable to support the head when the infant is pulled to a sitting position. Some reflexes are also included during their stages of developement such as; Babinski reflex when the toes fan outward when sole of foot is stroked and aslo Moro reflex (startle reflex) which extends arms then bends and pulls them in toward body wit a brief cry, it is often triggered by loud sounds or sudden movements. Other physical developements are Palmar hand grasp which the infant closes hand and "grips" your finger,Placing when the leg extends when sole of foot is touched, Plantar grasp when infant flexes the toes and forefoot, Rooting and sucking- turns head in search of nipple when cheek is touched and begins to suck when nipple touches lips, Stepping and walking the child takes brisk steps when both feet are placed on a surface, with body supported, Tonic neck response when the left arm extends when infant gazes to the left, while right arm and leg flex inward, and vice versa.
Motor Skills: The motor skills that are listed below invloves the ages from a newborn baby to a 6 month old child.
● kick their legs
● roll over
● sit with support
● begin to crawl
● likes to bounce with support
● put toys in their mouth
● reach for objects
● hold toys
● bat at toys/mobiles
● bang toys together
● throw toys
The newborn goes through the first stage of Ericksons development stages which is BasicTrust vs. MIstrust. This stage invloves developing trsust which is the first task of the ego, and it is never complete. The child let mother out of sight without anxiety and rage because she has become an inner certainty as well as an outer predictability. The balance of trust with mistrust depends largely on the quality of maternal relationship.
In PIagets stages of cognitive developmental stages, newborns are known to interact with their environment entirely through reflexive behaviors. They do not think about what they're going to do, but rather follow their instincts and involuntary reactions to get what they need: food, air, and attention. Piaget believed that as babies begin to grow and learn about their environment through their senses, they begin to engage in intentional, goal-directed behaviors. In other words, they begin to think about what they want to accomplish, how to accomplish it, and then they do it. This is also when infants develop object permanence, which is the ability to understand that something still exists even if it can't be seen. These two milestones, goal-directed behavior and object permanence,...
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