Physical Assessment

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CHAPTER III
PHYSICAL ASSESSMENT Physical assessment of client was done last August 6, 2013.
General Observation
Our patient is a 13 days old infant who was diagnosed with Neonatal Sepsis. According to Sigmund Freud’s Stages of Psychosexual Development, our patient is in the Oral Stage; wherein infant's primary source of interaction occurs through the mouth, so the rooting and sucking reflex is especially important. The mouth is vital for eating, and the infant derives pleasure from oral stimulation through gratifying activities such as tasting and sucking. Because the infant is entirely dependent on his mother and other significant others during feeding, the infant also develops a sense of trust and comfort through this oral stimulation. The primary conflict at this stage is the weaning process wherein the child must become less dependent to the ones who feeds him. If fixation occurs at this stage, Freud believed the individual would have issues with dependency or aggression. Oral fixation can result in problems with drinking, eating, smoking or nail biting. The ideal weaning of a child from breastfeeding to avoid oral fixations is up to 2 years.
In relation to our client, at the age of 13 days old, he was already weaned from his mother, because the mother claims to have less breast milk that is why she opted to choose mix feeding wherein they use formula milk at the same time the breast milk is being expressed and being transferred to a bottle.
* Vital signs:
The vital signs of our patient during physical assessment done last August 6, 2013 are as follows: Respiratory Rate of 69 breaths per minute, Cardiac Rate of 130 beats per minute and Temperature of 37.1ᵒC. His anthropemetric measurements are as follows: length of 53 cms, head circumference of 35 cms, chest circumference of 33 cms, abdominal circumference of 35 cms and weight of 2.9 kgs. Capillary refill time ranges from 1 – 2 seconds.
Skin
The patient’s skin is warm to touch without edema,

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