DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.
COLLEGE OF NURSING
1st Semester, S.Y. 2019-2020
Interviewer: Wyeth Earl P. Endriano Clinical Group: E
Clinical Instructor: Socorro Salvacion-Gasco, D.M, H.R.M, M.N, RN
Patient’s Name: Age: Gender:
Address:
OBJECTIVE INTERVENTIONS RESULTS
Establish Rapport with Introduce self:
the client/Significant Name
other(s). School
Course
Explain to the significant other the purpose
of the visit- make it clear to the
client/significant other that interview and
thorough physical assessment is done to
obtain baseline data on her infant.
Acknowledge progress and development
Communicate often- schedule a regular
parent/caregiver meetings
Distribute printed materials:
Pamphlets
Newsletter
Other IEC materials
Ask family if communication is effective and
efficient. If not, change approach.
Obtain baseline data of Obtain biographical data of the mother or
the infant from the caregiver:
significant other(s). Name
Age
Birthday
Occupation
Address
Civil Status
Obtain biographical data of infant from the
mother/care giver:
Infant’s Name/Nickname
Infant’s age
APGAR Score
Amniotic Fluid/Volume
Weight
Anthropometrics
Who is the infant’s primary health care
provider, and when was the infant’s last
well-child care appoinyment.
Where does the infant live?
Do the parents and infant live in the same
residence?
Are parents divorced married, single,
divorced, LGBTQ?
Who else lives in the residence?
Parents age
Is the infant adopted, foster, or natural?
Ethnic origin/Religion
Determine the Occupation of the parents
Determine who makes decisions regarding
to health care.
Obtain History of Present illness/concerns:
Interview significant other/Primary care
giver of the general health status of the
infant.
Obtain data on personal health history:
Ask about the mother’s pregnancy
Determine mother’s pregnancy status
Determine if pregnancy was
planned/Determine how she found out she
was pregnant.
Determine when the mother had her first
prenatal check-up
Ask about the mother’s general health when
pregnant.
Ask if she had any problems with the
pregnancy
Ask if she had any accidents during the
pregnancy.
Ask if she had taken any medication during
the pregnancy,
Ask if she is using any tobacco, alcohol or
drugs during the pregnancy
Ask about the delivery of the newborn/infant
Information on the duration of the labor
Ask if there were PROM (Premature
Rupture of Membranes)
Ask for Group B Streptococcus (GBS)
status.
Ask if RhoGAM was given.
Ask if there was any late decelerations of
contraction
Ask if there was Artificial Rupture of
Membranes
Induction
Meconium
Shoulder dystocia
Ask if large/small for gestational age
(LGA/SGA)
Ask if the baby had Hip dysplasia
Where was the infant born (hospital, home,
with or without a midwife or other care
provider)
Type of Delivery
Ask if there was an anesthesia used during
delivery the delivery. If there was, what type
was the anesthesia. Was there any
complication?
Were there any problems during the
delivery? Did you have any vaginal
infections at time of delivery?
What was the infant’s apgar score at 1 and 5
minutes?
What were the infant’s weight, length, and
head circumference? Did the infant have any
problem after birth (feeding, Jaundice)
Ask about past illnesses or injuries
Has the infant been hospitalized?
Has the infant ever had any major illnesses?
What immunization has the infant received
thus far?
Has the infant had any reactions to
immunizations?
Does the infant have any allergies? If so,
what is the specific allergen? How does the
infant react to them?
What Prescriptions, over-the-counter
medication, devices, treatments, and home or
folk remedies is the infant taking? Please
provide the name of the drug, dosage,
frequency, and reason it is administered.
Obtain Family History
Ask if there are any chronic health conditions
in the family
Make a genogram of two generations
Determine if the infant have a family
members with communicable diseases.
Obtain data of the infant’s Lifestyle and
Health Practices
Ask if the infant is bottle or breast fed.
Ask what fluids does the infant eat or drink.
Ask about the infant’s sleeping pattern.
Ask in what position does the infant sleep.
Obtain Objective Data Skin, Hair, Nails
on the physical Ask if infant had any changes in hair texture.
development of the Ask if infant had exhibited scaling on the
infant (Review of the scalp
systems) Ask if infant was exposed to any contagious
disease such as measles, chickenpox, lice,
ringworm, scabies, and the like?
Ask if the infant have ever had any rashes or
sores. (did the infant had any excessive
burning or burns)
Check if the infant have any birthmarks.
Head and Neck
Ask if the infant had a head injury.
Ask if the infant have head control (what age
did this occur)
Eyes and Vision
Ask if the parents noticed any unusual eye
movements.
Ask if the infant cross eyes excessively
Ask if infant blink when necessary
Ask if the infant can focus on moving objects
Ask if the infant’s pupil appear cloudy.
Ears and Hearing
Ask if the infant turn his/her head to human
voice. Does infant respond to loud noise?
Ask if infant had frequent ear infections.
Ask if there is anyone who smokes around
the infant.
Mouth, Throat, Nose, and Sinuses
Ask if the infant have any teeth
Ask if infant attends day care
Thorax and Lungs
Ask if the infant ever had cough, wheezing,
and shortness of breath, grunting, nasal
flaring, and chest retractions during the day,
at night or during feedings. If so, when does
it occur?
Ask if infant had frequent severe colds
Heart and Neck Vessels
Ask if infant become fatigued or short of
breath during feedings.
Peripheral Vascular System
Ask if infant have ever experienced bluing of
extremities.
Ask if infant have experienced bluing of the
skin, lips and/or nail beds.
Abdomen
Ask if the mother is breast or bottle feeding.
What food does the infant eat? Do you prop
the infant’s bottle? Do the mother put the
infant to bed with a bottle?
Ask if infant ever had any vomiting
Ask if infant exhibited symptoms of
abdominal pain ( drawing knees to chest,
excessive, inconsolable crying, cries when
eating, or cries excessively when haing a
bowel movement/urination. Allow the patient
to describe.
Genitalia
Ask how often the infant urinates. How many
wet diapers do you change per day?
Ask if the infant is prone to frequent diaper
rash.
Ask what intervention are made to reduce the
rash if present.
Anus and Rectum
Ask how often your infant have bowel
movements. What does it look like?
Ask if there are any history of bleeding,
constipation, diarrhea, or haemorrhoids.
Musculoskeletal
Ask if infant have ever had limited range of
motion, joint pain, stiffness, paralysis
Ask if infant had any fractures.
Ask if the mother noticed any bone
deformities.
Neurologic System
Ask if the infant had ant seizure
Ask if infant had any problem with his/her
motor coordination.
PHYSICAL ASSESSMENT Explain to the client(s) the purpose of the assessment
to identify the normal physiological development of
the infant, to provide early detection of changes and
problems and prompt treatment if found out that
there is indeed a problem.
Observe the general Appearance – Assess for:
appearance and hygiene Symmetry
Obvious deformity
Smell
Size
Muscle tone
Sex
Posture
Behavior
Crying
Lethargic
Responsive
jittery
Obtain data on Vital Obtain Axillary Temperature (36.4-37.2 C)
Signs Inspect and auscultate lung sounds
Monitor respiratory rate (30-60 bpm)
Auscultate apical pulse (120-160 bpmP)
Evaluate infant growth Weigh
and development by Body length
obtaining the Head circumference
anthropometric Chest circumference
measurements. Abdominal circumference
Mid-arm circumference
Assessment of the SKIN HAIR AND NAIlS
infant’s body head to toe Assess for skin color, odor, and lesions
Palpate for texture, temperature, moisture,
turgor, and edema.
Inspect and palpate hair
Inspect and palpate nails
HEAD, NECK, AND CERVICAL LYMPH
NODES
Inspect and palpate the head
Test head control, head posture, and ROM
Inspect and palpate the face
Inspect and palpate the neck
EYES
Inspect the external eye
Observe eyelid placement, swelling,
discharge, and lesions
Inspect the lacrimal duct
Inspect the sclera and conjunctiva for
color, discharge, lesions, redness, and
lacerations.
Observe for the iris and the pupils
Inspect eyebrows and eyelashes
Perform visual acuity tests
Perform extraocular muscle tests
Perform ophthalmoscopic examination
EARS
Inspect external ears
Inspect internal ear
Inspect Hearing acuity
INSPECT MOUTH AND THROAT
Inspect mouth and throat- note the condition
of the lips, palates, tongue and buccal
mucosa.
Assess the condition of gums. When
teeth appear, count teeth and note
location.
Note the condition of the throat and
tonsils. Observe the insertion and
ending point of frenulum
Inspect nose and sinuses
THORAX
Inspect the shape of the thorax – (pectus
excavatum, pectus carinatum) (smooth,
rounded, and symmetric)
Observe respiratory effort
Percuss the chest
Auscultate for breath sounds and
adventitious sounds
BREAST
Inspect and palpate breast – Note shape,
symmetry, color, tenderness, discharge,
lesions, and masses.
HEART
Inspect and palpate the precordium
Auscultate heart sounds
ABDOMEN
Inspect the shape of abdomen
Inspect the shape of the abdomen
Inspect umbilicus
Palpate for masses and tenderness
Palpate the liver
Palpate spleen
Palpate kidneys
Palpate bladder
Genitalia
Inspect external genitalia
Anus and rectum
Inspect the anus
Assess infant’s reflexes Assess for deep tendon and superficial reflexes:
Blink reflex; disappears by 3-4th month
Rooting reflex; disappears by 3-4th month
Sucking reflex; disappears by 10-12th month
Extrusion reflex; disappears by 4th month
Tonic neck reflex; disappears by 4-6th month
Moro reflex; disappears by 3rd month
Babinski reflex; disappears within 2 years
Screen for cognitive, Gross Motor Development
language, social and Balance head well when sitting
gross motor Sit with slight support
development Pull feet up to mouth when supine
Grasp object with whole hand
Hold one object while looking at another
Cognitive Development
Infant explores objects by grasping them
with the hands or mouthing them.
Infant develop secondary circular
reaction: very mobile
Language development- Assess ability to coo,
laugh, and squeal by 5 months
Social development- Assess infant’s ability to cry
to bring attention, smiles in response to smile of
others and shows fear of strangers.
Assess family’s The family should set and commit to these
readiness of care for the
standards:
infant Warm, responsive relationships.
Provision of healthy and safe environments.
Caregiver should have competence.
PATIENT EDUCATION Promotes the infant’s and the family’s health
development.
Promoting infant’s Teach family about infant safety
safety Aspiration prevention
a) Be certain any object an infant can grasp and
bring to the mouth is either safe to eat or too
big to fit in the mouth. Do not offer foods
such as popcorn or peanuts.
b) Store baby powder out of reach; inspect toys
and pacifiers for small parts that could be
aspirated.
Burns
a) Test warmth of formula and food before
feeding .
Falls
a) Never leave an infant on an unprotected
surface, such as a bed or couch, even if the
infant is in an infant seat.
Poisoning
a) Never present medication candy, buy
medications in containers with safety caps,
put away in a high cabinet immediately after
use, never leave medication and poisons in
locked cabinets.
Drowning
a) Do not leave infants alone in a bathtub or
unsupervised near water.
General
a) Be aware some infants are more active,
curious and impulsive and therefore is more
vulnerable to unintentional injury of others
b) Be aware of the frequency of injury is
increased when parents are under stress. Take
special [precautions during these times.
Promote safety with siblings
a) Remind parents that children under age 5
years of age, as a group, are not responsible
enough or knowledgeable enough about
infants to be left unattended with them.
b) Remind parents that siblings may introduce
an unsafe toy or engage in play that it too
rough for the infant.
Promoting nutrition of Teach the mother that the best food for an infant
the infant during the first 12 months of life (and the only
food necessary for the first 6 months) is
breastmilk.
Teach the mother about the key components of a
good complementary food:
Staple/ starchy foods
Protein rich foods
Vegetables and fruits
Teach the mother about the recommended dietary
allowances of infants.
Calories
o Requires about 350 to 500 calories
and in one year from 800-1,200
calories
Proteins - 0–6 months 9.1 g/day of protein
Fats and Lipids - 0–6 months 31 g/day of fat
Carbohydrates - 0–6 months 60 g/day of
carbohydrate
Vit. D - 0–12 months 5 µg (200 IU)/day
Vit. A - 0–6 months 400 µg Retinol Active
Equivalent/day
of vitamin A
Vit K. - 0–6 months 2.0 µg/day of vitamin K
Vit. E - 0–6 months 2.0 µg/day of vitamin K
Vit. C - 0–6 months 40 mg/day vitamin C
Vit. B 12 - 0–6 months 0.4 µg/day of vitamin
B12
Folate - 0–6 months 65 µg/day of dietary
folate equivalents
Vit B2 or Riboflavin - 0–6 months 0.3
mg/day of riboflavin
Vit. B 6 - 0–6 months 0.1 mg/day of vitamin
B6
Vit B1 - 0–6 months 2 mg/day of preformed
niacin
Educate the mother that some of the nutrients
babies need to grow and stay healthy include:
Calcium. Helps build strong bones and teeth.
Fat. Creates energy, helps the brain develop,
keeps skin and hair healthy, and protects
against infections.
Folate. Helps cells divide.
Iron. Builds blood cells, and helps the brain
develop. Breast-fed babies should receive
iron supplements.
Protein and carbohydrates. They provide
energy and fuel growth.
Zinc. Helps the cells grow and repair
themselves
Your baby also needs vitamins such as:
Vitamin A. Keeps skin, hair, vision, and the
immune system healthy.
Vitamin B1 (thiamine). Helps the body turn
food into energy.
Vitamin B2 (riboflavin). Helps the body turn
food into energy, and protects cells from
damage.
Vitamin B3 (niacin). Helps the body turn
food into energy and use fats and protein.
Vitamin B6. Keeps the brain and immune
system healthy.
Vitamin B12. Keeps nerve and blood
cells healthy, and makes DNA -- the genetic
material in every cell.
Vitamin C. Protects against infections, builds
bones and muscles, and helps wounds heal.
Vitamin D. Helps the body
absorb calcium from food, and keeps bones
and teeth healthy. Breast-fed babies may
need a D supplement.
Vitamin E. Protects cells from damage, and
strengthens the immune system.
Vitamin K. Helps the blood to clot.
For meal preparation:
Start with thick porridge, well mashed foods
The frequency of meals is 2-3 meals per day,
plus frequent breastfeeds
Depending on the child’s appetite/ 1-2
snacks may be offered
For the amount of each meal, start with 2-3
tabelespoonfuls per feed, increasing
gradually to ½ of a 250 ml cup.
Techniques for feeding solid food
Always supervise your baby’s meals.
Avoid foods that may cause choking.
Always supervise your baby’s meals.
Avoid foods that may cause choking.
Instruct the mother to try to introduce different
kinds of food every other day to identify food
preferences and skin allergies
Educate the mother that when introducing the
infant new food, food intolerances can develop on
the signs and synonyms of food allergies:
Skin rashes
Severe vomiting after eating
Hives like a skin rash (welts)
Diarrhea
Establish healthy eating patterns
Educating the mother of Bathing
infant care. a) Remind the mother that the infant does not
need a bath everyday
b) A complete bath can be omitted with only
the infants face, hands and diaper area to be
washed.
c) Teach parents to never leave children alone
during bath time.
d) Teach parents that bath time is a good
opportunity for a parent to touch and
communicate with the child.
Dental Care
a) Promote healthy tooth formation and prevent
tooth decay by exposing developing teeth t
fluoride with a water level of 0.3 ppm that
protects the tooth enamel.
Dressing
a) Reassure the parents that infants should be
easy to launder and simply constructed so
neither dressing nor undressing is a struggle
b) Inform the mother that her infant only needs
soft soled socks and soft clothing.
Sleep
a) Inform the mother that baby required 10 to 12
hours of sleep a night and one or several naps
during the day.
Exercise
a) Inform the parents that the infant benefits from
outings because sunlight provides a natural
source of vitamin D.
Encourage parents to let Educate the parents that newborn screening tests
the infant undergo look for developmental, genetic, and metabolic
screening tests disorders in the newborn baby. This allows steps
to be taken before symptoms develop. Most of
these illnesses are very rare, but can be treated if
caught early.
Document findings
