sample of mmdst

TABLES OF CONTENTS

I. Demographic data 2

II. Reason for Seeking Health 2

III. History for Present Illness 2

IV. Past Medical History 2

V. Heredo-familial History 4

VI. Developmental History 5

VII. Gordon’s Functional Health Patterns 12

VIII. Comprehensive Physical Examination 15

Cephalocaudal Assessment 17

Focused Assessment 24

IX. Diagnostic Test 25

X. Review of System 25

XI. Case Management 26

Medical 26

Surgical 26

Nursing management 27

XII. Appendices 29

1

I. DEMOGRAPHIC DATA

Initials of Clients’ Name: Sn.L

Address: Langkaan II, Dasmariñas City, Cavite

Age: 2 months old

Birth Date: September 28, 2010

Birth Place: Langkaan II, Dasmariñas City, Cavite

Gender: Female

Religion: Roman Catholic

Date of Interview: December 06 2010

Primary Informant: The mother of the client

Secondary Informant: none

II. REASON FOR SEEKING HEALTH CARE:

The mother of the client just wants to maintain her baby’s health.

III. HISTORY OF PRESENT ILLNESS

The client is not experiencing any illness.

IV. PAST MEDICAL HISTORY

Childhood/ Adult Diseases

Not applicable

2

Injuries/Accidents

Baby Sn.L never experienced injuries and accidents.

Hospitalization

Baby Sn.L is not experience to be hospitalized but her mother carries her in the rural

health unit to administered vaccine.

Operation

Baby Sn.L was never undergoing in any operation.

Allergies

She has no allergies

Medication

She did not take medicine but she is now under of administering vaccination.

Immunization

The client is not yet fully immunized. She had BCG (September 29, 2010), DPT

(December 06, 2010), OPV (December 06, 2010) and Measles (December 06, 2010). She had no

Hepa B vaccine yet.

Last Examination:

Her last visited in Langkaan II Rural Health Unit was last December 06, 2010

3

V. HEREDO-FAMILIAL HISTORY

INTERPRETATION:

Family of Mr.A.L is composed of 4 members. The father is Mr. A.L, he is 39 years old,

and the mother is Mrs. Mf.L, she is 30 years old and their two kids are Sh.L, their eldest son, he

is 3 years old and the youngest daughter is Sn.L 2 months. Their family has not hereditary

disease both side.

4

VI. DEVELOPMENTAL HISTORY

A. J. Piaget’s Cognitive Development

Stage Special task (s) Evidences of Milestone

Achievement

Justification

SENSORIMOTOR Sub-stage:First habits and primary circular reactions phase 6 weeks

o "Coordination of

sensation and two types of schemes: habits (reflex) and primary circular reactions (reproduction of an event that initially occurred by chance). Main focus is still on the infant's body

o In this stage, this

type of reaction, an infant might repeat the motion of passing their hand before their face. Also at this phase, passive reactions, caused by classical or operant conditioning, can begin.

o The infant was not

do something, she just do is staring at m while I playing with her.

B. E. Ericson’s Psychosocial Development


Achievement

Justification

Infancy Trust vs. Mistrust o In this stage the mother needs to ready to teach her daughter to trust other and to get rid of the anxiety to other

o My client is only two she have no yet cares about what happening to her environment, but when I perform palmar grasp reflex she refused me but when her mother do the tester she grasp the finger of her mother

5

http://en.wikipedia.org/wiki/Operant_conditioning

http://en.wikipedia.org/wiki/Operant_conditioning

http://en.wikipedia.org/wiki/Classical_conditioning

C. S. Freud’s Psychosexual Development


Achievement

Justification

Oral o Center of pleasure: mouth (major source of gratification & exploration)

o Primary need: Security

o Major conflict: weaning

o In this stage the infant is always do the sucking reflex because this is their way to satisfy their curiosity and to release their stress

o While I interviewing her mother I saw that she sucks her own finger.

D. J. Fowler’s Spiritual Development

Stage Special task (s) Evidences of Milestone Achievement

justification

Pre-stage:

Undifferentiated faith

o Trust, hope and love compete with environmental inconsistencies or threats if abandonment.

o In this stage the infant wants always is with her mother. She had also anxiety to the other or to the person who is stranger for her.

o The infant is comfortable and satisfy with her mother hands.

E. L. Kohlberg’s Moral Development


Achievement

Justification

6

(Pre-Conventional)

Level 1: Obedience and punishment orientation

o (Obedience and punishment driven), individuals focus on the direct consequences of their actions on themselves.

o In this stage the mother will be ready to educate her daughter to be obedient.

o The mother of the client doesn’t need to discipline her daughter at this time because her baby is still innocent.

F. R. Havighurst’s Development Task


Achievement

Justification

Infancy o Dependent with the mother

o In this stage it is normal to be dependent to the mother

o The client cannot do anything; she cannot do anything without her mother. Like for example; to feed her, to dressed her, to bathe her and other

G. Williams Metro Manila Development Screening Test (MMDST)

PERSONAL-

SOCIAL

SCORE ADMINISTRATION JUSTIFICATION

Regards Face Passed I place the child on his

back. Then I come face

to face within 12 inches

of the infant.

The infant looks at me and

she stares ay me

Smiles Responsively Refused I smile and talk to the

infant but I do not touch

her.

While talking to the infant

the infant make sounds. It

looks like that she is talking

7

to me.

Smiles spontaneously Refused During the test observe

if the infant smiles at

tester or parent without

any stimulation either

by touch or sound.

During the test regards face

the infant always stare at

me when I look into her.

Feed Self Cracker Failed I asked the parent if the

child feeds herself a

cracker.

She cannot feed herself

Resist toy pull Failed I give the infant a rattle.

While she is playing

with it I gently pull it

away from her.

The infant didn’t do the

activity

Plays Peek a Boo Failed I make a small hole in

the middle of the paper

with a pen. When the

infant is looking at me I

hide my face within the

paper. Then, I look

around within the paper

twice and says, “peek a

boo.” I look through the

hole too see if the child

is waiting for me to

reappear.


activity

Works for toy out of

reach

Failed I place the rattle on the

table a little out of her

reach. (do not leave the


activity

8

toy out of reach too long

or too far away this may

upset the child)

FINE-MOTOR

ADAPTIVE


Follows to Midline Failed I hold the red scarf

about 6 inches in front

of the child’s face, and

then I shake the scarf to

attract the child’s

attention. Then I move it

from one side in an arc

over the midline of the

infants head to the other

side. Then I repeated it 3

times.

The infant didn’t follow the

red scarf

Follow past midline Failed Same as the

administration of the

test follows to midline.

The infant didn’t follow the

red scarf

Hands together Passed While the assessment is

going on, I observed if

the infant can put her

hands together.

Based on what I observed

the infant can put her hands

together.

Grasp Rattle Passed While the infant is being

held by her parent. I

place the rattle touching

the tips of the child’s

finger.

The infant grasp the rattle

for a few seconds.

9

LANGUAGE SCORE ADMINISTRATION JUSTIFICATION

Responds to bell Passed I hold the bell where the

child doesn’t see it. I

first put the bell in her

left and ring it. Then to

her right and ring it

again.

The infant turns her head in

the left side where I first

ring the bell. Then turns her

head to the right where I

ring the bell again. This

shows that the child is

looking from where the

sound is coming.

Vocalizes not crying Passed I asked the mother

“panu nyo po nalalaman

pag nagugutom na si

baby? Eh pag inaantok?

Eh pag naiinitan?”.

According to the mother

the infant is crying when

she is hungry

Laughs Failed During the assessment I

observe the infant if she

will laugh.

I asked the mother

“tumatawa napo ba sya

ng malakas kahit hindi

kinikiliti?”

The infant doesn’t laugh

during the assessment

Squeals Passed During the assessment I

observe if the infant will

make high-pitched

happy squealing sounds.

I asked the mother

“Tumitili nap o ba sya

ng parang masayang

The infant doesn’t make

any high- pitched sound.

10

Masaya? Paano po sya

natili?”.

GROSS- MOTOR

BEHAVIOR


Stomach lifts head Passed I put the infant on her

stomach in a flat

surface.

The infant lifts her head up

to 90 degrees.

Stomach chest up

arm support

Passed Same as the procedure

of stomach (sto) lifts

head.

After the infant lifts her

head up to 90 degrees she

performs chest up arm

support.

Sit head steady Passed While the infant is

sitting in the mother’s

lap. I observe if she can

lift her head upright and

steady.

The infant can carry the

weight of her head because

she can lift her head in

upright position and she

can hold it steadily.

Bear weight on legs Failed I asked the mother to

hold her baby in upright

position so that her feet

rest on the floor. Then I

asked her to slowly

loosen her hand support

but do not release the

infant completely.

The infant can’t stands by

her two legs her

11

VII. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS\

1. Health Perception- Health Management Pattern

Interaction:

Her mother takes her daughter with breastfeed.

Observation:

During the interview, I noticed that Sn.L is have a good appetite in breastfeeding

Measurement:

NA

2. Nutrition and Metabolic Pattern

Interaction:

Baby Sn.L only takes from now is breastfeed from her mother.

Observation:

The client is completely nourished.

Measurement:

Not applicable

3. Elimination Pattern

Interaction:

12

She had regular defecates. According to her mother her stool is yellowish in color.

Observation:

Not applicable

Measurement:

The client defecates once or twice a day.

4. Activity- Exercise Pattern

Interaction:

Not applicable.

Observation:

Not applicable.

Measurement:

Not applicable.

5. Sleep-Rest Pattern

Interaction:

She is always sleeping. After her breastfeed she takes her sleep it last an hour.

Observation:

NA

Measurement:

She has no standard sleeping.

6. Cognitive- Perceptual Pattern

Interaction:

Not applicable.

Observation:

13

Not applicable.

Measurement:

Not applicable.

7. Self-Perception- Self- Concept Pattern

Interaction:

Not applicable.

Observation:

Not applicable.

Measurement:

Not applicable.

8. Role- Relationship Pattern

Interaction:

Not applicable.

Observation:

Not applicable.

Measurement:

Not applicable.

9. Sexuality- Reproductive Pattern

Interaction:

Not applicable.

Observation:

14

Not applicable.

Measurement:

Not applicable.

10. Coping- Stress Tolerance Pattern

Interaction:

Not applicable.

Observation:

Not applicable

Measurement:

Not applicable

11. Value- Belief Pattern

Interaction:

Not applicable.

Observation:

Not applicable

Measurement:

Not applicable

I. COMPREHENSIVE PHYSICAL EXAMINATION

A. Vital Signs Date / Time of Exam: December 06, 2010

T = 36.9C

15

PR = 152 bpm

RR = 56 cpm

CR = 152

B. Anthropometric Data

Weight: 4.4 kg

Head circumference: 39 cm

Chest circumference: 41 cm

Abdomen circumference: 40 cm

C. General Appearance

General Appearance

1. Body build and height-weight proportionality

The client’s appearance is appropriate to her age. She has a normal growth

according to her Infancy and Development Card.

2. Over-all hygiene and grooming

Based on my observation the client has a good hygiene and grooming. She looks

very neat and presentable when I arrived.

3. Body and breath odor

The client has no bad breath and body odor.

16

D. Cephalocaudal Assessment

Body Part

Examined

Actual Finding Normal Finding Clinical Significance

INTEGUMENT

Skin

Color and

uniformity

Her skin is pinkish

white in color &

uniform

She has small

birthmark in her

right leg. It is color

brown.

The skin is brown

and pinkish white in

color in color

Inspection reveals

evenly colored skin

tones without

unusual or

prominent

discoloration.

Small amount of

melanin are common

in whiter skins, while

large amounts of

melanin are common

in olive and darker

skins. Carotene

accounts for a yellow

cast. Pallor skin is

seen in arterial

insufficiency,

decreased blood

supply, and anemia.

Central cyanosis

results from

cardiopulmonary

problem whereas

peripheral cyanosis

results from

vasoconstriction.

17

Edema

Lesions

She is negative in

edema

She has no lesions

cephalocaudal

Skin rebounds and

does not remain

indented when

pressure is released

Smooth without

lesions. Stretch

marks (striae),

healed scars,

freckles, moles or

birthmarks are

common findings.

* H.A. - page 323

Jaundice mostly

results from liver

problem.

Moisture

Temperature

Her skin is soft and

smooth and it is not

dry.

Her skin temperature

in body and

extremities is

uniform and in

normal range

Skin is moist

skin temperature

should be uniform

within normal range

Skin is normally a

warm temperature.

Increase moisture or

diaphoresis may occur

in condition such as

fever. Decreased

moisture occurs with

dehydration.

Cold skin may

accompany shock or

hypotension. Cool skin

may accompany

arterial disease. Very

18

Turgor Normal turgor in her

skin.

Skin pinches easily

and immediately

returns to its

original position.

* H.A. - page 323

warm skin may

indicate a febrile state

Decreased turgor is

seen in dehydration.

Hair

Evenness of

growth

Body hair

Her hair is short, thin,

soft and shiny. It is

brown in color and

it grows evenly.

Positive presence of

lanugo in her back

especially in her

shoulder. It is fine,

downy hair and it is

very dark black color

hair.

Hair may feel thin,

straight, coarse,

thick or curly

Hair should grow

evenly.

Should be soft and

shiny.

H.A. - page 355

Lanugo is fine,

downy hair can be

present on the skin.

This is most

prominent over the

temples of the

forehead and on the

upper arms,

shoulders, back and

the pinna of the

ears.

Nutritional

deficiencies may

cause patchy gray

hair in some clients.

Lanugo helps to the

infant to maintain the

body temperature.

19

( *H.A – page 921)

Nail

Plate and shape

Bed color

Surrounding

tissues

The clients nail is

properly attach to the

nail bed and she has

rounded nail shape

Her nails both hand

and toenails is color

pinkish white.

Soft tissue and intact

skin.

The nail is

approximately 160º

angle and it is

rounded and also the

nail is properly

attach to the nail bed

Nail bed is pink or

brown

Soft tissue and

without any lesions.

* H.A. - page 355

If there is an early

clubbing (180-degree

angle w/ spongy

sensation) and late

clubbing (greater than

180-degree angle) can

occur from hypoxia.

Spoon nails may be

present w/ iron

deficiency anemia.

Pale or cyanotic nails

may indicate hypoxia

or anemia. Yellow

discoloration may be

seen in fungal

infections or psoriasis.

Nail pitting is common

in psoriasis.

The cuticle provides

protection.

Blanch test The color of her nail

bed return into its

normal color within

2 seconds

Pink tones returns

immediately to

blanched nailbeds

when pressure is

released

If there is slow

(greater than 2 sec.)

capillary refill w/

respiratory or

cardiovascular

20

* H.A. - page 355

diseases that cause

hypoxia.

HEAD

Skull and Face

Size, Symmetry

and Shape

Eyes for edema

and hollowness

The client head is

symmetrical, not

deformed and has a

normal size

proportional to her

body.

Absence of edema

and hollowness

Head is symmetrical

No deformities

Head size and

shape vary,

especially in accord

with ethnicity.

Absence of edema

and hollowness

* H.A. - page 371 & 372

If there is

acromegaly, the skull

and facial bones are

larger and thicker

because of increased

production of growth

hormone.

Acorn-shaped,

enlarged skull bones

are seen in Paget’s

disease of the bone.

Presence of

hollowness may be

due to lack of sleep

or rest, and stress.

Eyes and Vision

Eyebrows for

distribution &

alignment,

quality &

movement

Evenly distributed

hair in the

eyebrows, aligned,

fine and able to

move

Aligned, evenly

distributed hair,

fine and able to

move eyebrows.

* H.A. - page 372

Their function is to

protect the eye from

sweat and rain, and it

is also used as a

facial expression.

21

Eyelashes for

evenness of

distribution &

direction of

curl

Evenly distributed

hair in the

eyebrows, aligned,

fine and able to

move.

Eyelashes are equally

distributed and

sweeping upward

from the upper lids

and downward

from the lower lids

* H.A. - page 400

Their function is to

protect the eye from

sweat and rain, and it

is also used as a

facial expression.

Eyelids for

surface

characteristics,

position in

relation to cornea

The color of her

eyelids is like the

color of her skin.

Absence of

swelling, lesions,

and discharges.

Eyelids depend on

the color of skin

tone, absence of

swelling, lesions

and discharges.

* H.A. - page 400

If there is presence

of lesions or

swelling it is caused

by trauma.

Ears and Hearing

Auricles for

color, symmetry

and position

Her ears is also

pinkish white in

color same as her

skin. It is positioned

normally and

proportional to her

head.

The ear should match

the flesh color of

the rest of the

patient’s skin

should be

positioned centrally

and in the

proportion of the

head. The top of the

ear should cross an

imaginary line

drawn from the

outer canthus of the

eye to the occiput

Misaligned or low-set

ears may be seen with

genitourinary

disorders or

chromosomal defects

22

* H.A. - page 441

External canal

for cerumen,

lesions, pus or

blood

The client has no

cerum and her ear

has no discharges

and no lesions and

swelling.

Cerumen should be

moist and not

obscure the

tympanic membrane

no foreign bodies,

redness, deformities

and lesions

* H.A. - page 441-

442

Foul-smelling, sticky,

yellow discharge otitis

externa or impacted

foreign body.

Nose and Sinuses

Nose deviation

in shape, size,

color, flaring,

discharge;

Nose is

symmetrically in the

middle of the face,

same as the color of

her skin, no

deformities and no

discharge.

Nose is

symmetrically in

the middle of the

face

color is depends upon

the race

no deformities

no discharge

* H.A. - page 450

Flaring or discharges

is an abnormal signs.

Mouth /

Oropharynx

Lips for

symmetry of

contour, color,

texture,

moisture,

lesion

Her lips have parts

that have whitish

color.

pink and moist

smooth

no evidence of

lesions

flaccid

* H.A. - page 457

It shows that the infant

is in healthy condition.

23

A: breath sounds normal breathing

sounds

air rushing through

the respiratory tract

during inspiration

and expiration are

as follows:

o bronchial

o bronchovesicular

o vesicular

* H.A. - page 538

It clarifies that she got

a normal finding

because she has a

normal breathing

pattern.

E. Focused Assessment

Reflex mechanism of the infant

Reflex Actual Finding Normal Finding Clinical Significance

Rooting reflex The infant would turn her head toward the side that was where my finger is.

Up until 3 or 4 months of age, the will turn the head toward the side that was stroked.

Central nervous system disease such as frontal lobe lesions accounts for an absent rooting reflex.

Sucking reflex The infant sucks her mother breast

The sucking reflex occurs up to approximately 10 months.

A premature infant or a breast-fed infant of a mother who ingest barbiturates does not exhibit the reflex secondary to central nervous system depression.

Palmar Grasp reflex

The infant grasp the finger of her mother

Normally, the infant grasps the finger in flexion

The etiology is attributed to frontal lobe lesions

24

Tonic Neck reflex The head of the infant turned extend to the left while her upper and lower extremities was on the side

The upper and lower extremities on the side to which the jaw is turned extend, and the opposite arm and leg flex.

Cerebral damage is suspected if the tonic neck reflex is seen

Plantar Grasp reflex

The infant toes was curl down when I give pressure to her feet

The infant toes curl down until 8 months of age

An obstructive lesion such as an abscess or tumor can cause the plantar grasp reflex to be absent on the affected side. Bilateral absence can occur in CP

VIII. DIAGNOSTIC TEST

N/A

IX. REVIEW OF SYSTEM

INTEGUMENTARY/ SKIN

“malambot at makinis ang balat ng baby ko, mabango po kaya masarap halikan.”

HAIR

“ayy naku kalbo yan, sabagay sanggol pa naman siya.”.

EYES

“wala naman akong nakikita masama sa mata niya, lagi lang yan nakatingin sa taas.”

EARS

“walang problema to sa tenga, bata pa ehh”

NOSE

25

“wala din siyang problema sa ilong ko.”

MOUTH

“ayun lagi lang maputi ang mga labi, nadede kasi skin.”

THROATH

“wala naman, at saka ang bata pa nito, hindi pa ito nagsasalita”

RESPIRATORY

“ayan mabilis huminga, pero dib a normal lang naman tung ganun sa mga sanggol.”

CARDIOVASCULAR

“wala naman, tsaka wala kaming lahing may sakit sa puso.”

GASTROINTESTINAL

“madalas iyang dumudumi halos araw araw.”

GENITOURINARY

“ayy kung madalas siyang dumumi, mas madalas iyang umihi, maraming beses sa isang araw”

II. CASE MANAGEMENT

A. Medical (Not Applicable)

1. Pharmacologic Intervention (Not Applicable)

2. Dietary Prescription / Restriction (Not Applicable)

3. Procedures (Not Applicable)

B. Surgical (Not Applicable)

1. Pre-operative

2. Intra-Operative

26

3. Post-Operative

C. Nursing Management

A. List of Nursing Problems

1. Effective breastfeeding related to basic breastfeeding knowledge

B. Prioritization of Nursing Problems

Effective breastfeeding related to basic breastfeeding knowledge

Cues/data Weight Computation Actual

score

Justification

1. Nature and extent 1- Wellness State

1/3 * 3 0.9 The infant is in the wellness state. She is feed by breastfeed of her mother which is good for her.

2. Modifiability 2- Easily Modifiable

2/2 * 2 1 It is easily modifiable because they don’t need to spend some money for the milk of the infant.

3. Preventive potential

1- Low Preventive Potential

1/3 * 3 0.9 It is low preventive because they don’t have to prevent in breastfeeding.

4. Salience 0- Not perceived as a problem

0/2 * 2 0 It is not perceived as a problem because breastfeeding is very well for the infant’s health.

Total 2.8

27

C. Plans for Nursing Action

a) Nursing Care Plans

Effective breastfeeding related to basic breastfeeding knowledge

Assessment Diagnosing Planning ImplementationSubjective: “malakas

dumede to” Sa akin lang

siya dumedede, hindi iyan nadede sa bote”

Objective: Infant is

content after feedings

Effective breastfeeding related to basic breastfeeding knowledge as manifested by maternal verbalization of satisfaction with the breastfeeding process.

After 1 hour of nursing intervention, the mother will be able to:

Verbalize understanding of breastfeeding techniques

Demonstrate effective techniques for breastfeeding

The student nurse conducted health teaching regarding:

Demonstrate how to support and position infant

Keep infant with the mother

Encourage the mother to drink at least 2000ml of fluid per day or 8oz every hour.

Give handouts about the effective techniques for breastfeeding

To give comfortable and safe position to the infant

For unrestricted breastfeeding duration and frequency.

To avoid dehydration for the mother and to increase the milk in the breast of the mother

To have more knowledge about the effective breastfeeding

b) Teaching Plan

Not applicable

c) Discharge Plan

28

Not applicable

29

ONGOING APPRAISAL

1st day

When I arrived, I introduced myself to the mother of my client and explain to her what I am going to do. I also told her that I am going to assess her baby and fortunately she agreed. After that, I interviewed her and ask some questions regarding to her baby such as demographic data, Heredo-Familial Data and data’s that can help me to build the infant’s Gordon’s Functional Health Patterns. After that, I decided to do the assessment to the client, I try to the client the reflex if she can passed but when I give my finger to her she refused me but when her mother do that she grasp immediately her mother finger. While doing the interviewing I also observe their environment. After I completing the interviewing, assessing I decided to go and bid a goodbye to Mrs. Mf.L and then before I live them I show her an appreciation for her cooperation and kindness to me.

Pictures of baby Sn.L

30

sample of mmdst

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