Pedes Assignment
Simi Talawan July 16,2012
Clients Initals: G.C. Age: 20 Days
Room: 407-1 Hospital Day: 7/11/12 Diagnosis: Pneumonia
Immunization: Hep B, Polio, DTap Vital Signs: Bp 91/54 152 54 97.6
DataBase: Biological
· 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.
· Musculoskeletal: FROM
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-
Clients Initals: G.C. Age: 20 Days
Room: 407-1 Hospital Day: 7/11/12 Diagnosis: Pneumonia
Immunization: Hep B, Polio, DTap Vital Signs: Bp 91/54 152 54 97.6
DataBase: Biological
· 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.
· Musculoskeletal: FROM
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-