Growth and Development Case Study grp1

I.
PERSONAL DATA
Name of Child: Christian Jay Diego

Date of Birth: July 3, 2015
Place of Birth: Provincial
Age: 4 years old
Place of Delivery:
Address: Poblacion-4 Pasuquin, Ilocos Norte
Weight (present): 18 kg
Height: 110 cm
Number of siblings: only child
Name of parents
Mother: Raquel Diego Age: 35 years old
Educational attainment: College graduate Occupation: Elementary
Teacher
Father: Cathalino Diego Age: 38 years old
Educational attainment: Highschool graduate Occupation: Farmer
Civil status: Married
Religion: Catholic
Monthly income: Php. 20,000
Date of interview: November 7,2019
II. HEALTH HISTORY

a. Present Health History
Upon assessing Child X, We noticed that the patient is
experiencing Cough and Colds. We ask the patients father
b. Past Health History
November 4, 2019 according to his father Mr. C, Child X was
admitted in the --- for 3 days due to asthma. He was attacked by his
asthma during his playtime in their school. Child X has a shortness of
breath, tightness in in his chest and coughing. Mr. C verbalizes,
“marigatan nga aganges, agkupit barukong na ken permi pinag-uyek na.”
As a management to Child X’s asthma, parents tend to give him a
nebulizer in an electric version to lessen his suffering during the attack of
his asthma. Nebulizer turns liquid medicine into mist to help treat asthma
especially for children who aren’t old enough to properly use inhalers.
Child X has given a treatment by his doctor during his admittion in
----. PRESCRIPTION---In addition to his past health history, he has
completed his immunization and as a proof Mr. C showed us child X’s
immunization card.
c. Family Health History
III. Factors Influencing Growth and Development
a. Heredity/Genetics (presence of hereditary diseases)
According to the father of the patient, they don’t have any hereditary
diseases. As verbalized by “Awan met saksakiten mi nga naala mi kadigijay
nagannak mi Ma’am ”
b. Gender
According to the father of the patient, he is the one taking care of CJ while
his mother is working. When he is with his father, he is able to eat and behaves
well. As verbalized “Haan na kayat mangan ti adu nu addan mamang na ata syak
kanayun na kadwa mangan nukwa.”
c. Health (status, vitamin supplement)
The patient’s weight is 18kg and his height is 110cm. His Body Mass
Index (BMI) is 14.87 which is appropriate at his age. The patient’s vitamins are
CelinePlus and CherryPer taken once a day.
d. Intelligence
The patient’s mother is an elementary teacher. CJ inherited his parents

intelligence, especially that of his mother’s. Her mother’s also teaching him after
she gets home from work. That’s why CJ is very active in his school and always
participates and cooperates well.
e. Temperament
As what we have observed on our first and second visits, CJ is easily gets
distracted while his teacher is teaching. He cannot stay in one place and refrain
from playing with his toys or with his friends.
f. Environment (home environment, accidental hazards, attitude)

The house of the patient is under construction, and it may affect the
condition of the patient because of the cement or dusk that can trigger the child’s
asthma. Also the second floor of their house specifically on their terrace don’t
have yet rail support which is a risk factor for the safety of the child.
g. Nutrition (likes and dislikes, amount intake, height and weight)
The nutrients from the food that the patient’s eat was appropriate for the
nutrition of the child. He eat three times a day, also the parents of the child guides
him from what kind of foods should be eaten and to be avoided. The child loves
to eat all kind of vegetables like “malunggay” except “ampalaya”. His parents
allow him to eat junks foods and drink soft drinks in a minimal amount only. And
base on the food intake of the child we can see that it is appropriate to his height
and weight.
h. Socio- economic status (income adequate to meet basic needs)
The income of his parents is Php.22,000. Php.2,000 from his father’s

income in farming and Php.20,000 from his mother’s salary as a teacher. His
father verbalize that with this amount of money it is enough for them to meet their
daily needs. In addition to their source of income for daily living, as extended
type of family, his grandparents and his uncle also help them for some of their
needs.
i. Religion
Their religion is Roman Catholic and they believe in trinity which is God
the father, God the Son, and the Holy Spirit, and they also believe that there is a
place which is called purgatory. They strongly believe in superstitions, like
sweeping at night can keep away blessings. In regards to food there is no
restriction as long as it is good to eat, it is okay, except eating meeting during
“semana santa”.
j. Family structure
The type of their family is extended. The patient family live together with
his grandmother including his uncle. Most of the time his fathers is the one who
takes care of him, just like sending him to school and after his class his father
fetch him from school. Also his grandmother take care of him after school and
feed him. During weekends his mother is the one who will take care of him, and
that serves as their bonding.
k. Prenatal influence nutrition, drugs ,maternal diseases, planned, check-ups)
IV. DEVELOPMENTAL MILESTONES

a. Freud
b. Erickson
c. Havighurst
d. Piaget
GENERAL APPEARANCE
The patient speaks clearly and he interacts actively. He appears his stated age (4 years
old) and his gender is male. He is able to communicate and response to questions appropriately
and fully aware of his surroundings.
The patient is very well oriented to person, date, place and situation. His body parts
appear to be symmetrical. He is in good posture and can stand properly. His body build is
ectomorph.
The patient walks properly and can maintain balance without assistance. He also talks
clearly and can able to express his ideas in studying and in playing. And his clothing was
appropriate for a preschooler, and he appears clean and tidy.
V. PHYSICAL ASSESMENT
TPR/VS
•Temp = 36.8
•PR = 78 bpm
•RR = 24 bpm
Skin, Hair, Nails

Upon inspection of the skin, it is evenly colored skin tones without unusual or
prominent discolorations. With minimal odor, skin is intact and there are no reddened
areas. Skin is smooth, without lesions. Upon palpation, the skin is smooth and even,
with no lesions palpated. Skin is warm to touch. Upon palpation of the lower and
upper extremities, the skin rebounds and does not remain intended when pressure is
released.
Upon inspecting of the scalp and hair, the color is black and dry. The scalp is
clean and dry without sparse of dandruff.
Upon inspection of the nails, they are all clean with pink tones. Upon palpation,
the nails are hard, smooth and firm. Pink tone returns immediately after 1-2 seconds
when pressure is released.
Head and Neck

Upon inspection, the head is symmetric, round, erect and in the midline and
appropriate to the patient’s body size with no lesions visible. Neck is symmetric, with
head centered and without bulging masses. No enlargement or tenderness is present.
The face is symmetric with round appearance. No abnormal movements noted.
Upon palpation, the head is hard and smooth without lesions. The temporal artery
is elastic and not tender.
Upon palpation of the neck, neck is symmetric, head centered and without bulging
masses. The neck can move smoothly and the trachea is in midline. No swelling or
enlargement and no tenderness. No bruits are auscultated.
Eyes
The pupils are in the center of the iris, round, color black and reactive to light.
The Bulbar conjunctive is clear and moist. Underlying structures are clearly visible.
Sclera is white. Palpebral conjunctiva is free of swelling or lesions. No swelling or
redness appears over areas of the lacrimal gland. The puncta are visible without
swelling or redness.
Ears
Ears are equal in size bilaterally. No lesions, lumps, or nodules. Color is
consistent with facial color. The auricle, tragus, and mastoid process are not tender.
We performed the whisper test and the patient was able to correctly repeat the two-
syllable words as whispered and on the Romberg test, the client maintains position in
10 seconds without swaying.
Nose
Color is the same as the rest of the face; the nasal structure is symmetric with no
tenderness. Client is able to sniff each nostril. The nasal mucosa is dark pink and
moist. No signs of ulcers, scars or inflammation. Frontal and maxillary sinuses are
nontender to palpation, and no crepitus is evident.
Mouth and teeth

Upon inspection, lips are smooth and moist without lesions or swelling. The color
and consistency of tissues along the cheeks and gums are even. Gums are pink, moist,
and no lesions or masses. The teeth are yellowish and some teeth are decaying.
Tongue is pink, moist, a moderate size with papillae present.no lesions are present.
With foul odor noted. Jaws are aligned with no deviation seen with biting down.
Color and consistency of tissues along cheeks and gums are even.
Breast
The breast are symmetric and the color of the areola is brown, wide and non-
tender upon palpation. No nodules, scars and signs of other abnormal discharges.
Abdomen
No stretch marks or striae are visible at the abdomen. Upon palpation of the
abdominal skin is paler than the general skin tone. Abdomen is free from lesions or
rashes.
VI. RESULT MMDST TO INCLUDE INTERPRETATION
PERSONAL SOCIAL
FINE MOTOR
Fine motor is how CJ’s ability to see and to use his hands to pick-up
objects and draws.
We prepared tools for our patient to assess his fine motor abilities, and these are;
colored blocks, chiz curls, different sizes of sticks, ball, paper and pencil.
For the colored blocks, we instructed him to place the 6 pieces of blocks
on the top of other blocks. We also asked what the colors of the blocks are. For
the chiz curls, we instructed him to put the chiz curls in a bottle. For the sticks,
we showed him small and large sticks and asked him to pick the largest one. And
he chooses the large one. And verbalizes “kaykayat ko di dakkel jak kayat ti
bassit”. For the ball, we asked him to play with us by throwing, catching and
passing the ball. And with the paper and pencil, we instructed him by drawing a
square, circle, and cross. At first try, he didn’t want to draw and verbalizes “Jak
amu ag drawing”. Second try, he finally draws a square, circle and a cross. He
also drew a man in 3 parts and in 6 parts; head, 2 hands, 2 feets and body.
Surprisingly, all these test for his fine motor abilities are all successful, he
answered our questions correctly, and the child can do the task which is
appropriate for his age.
LANGUAGE
GROSS MOTOR
VII. NURSING CARE PLAN

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I.

Name of Child: Christian Jay Diego

Date of interview: November 7,2019

II. HEALTH HISTORY

c. Family Health History

III. Factors Influencing Growth and Development

a. Heredity/Genetics (presence of hereditary diseases)

c. Health (status, vitamin supplement)

The patient’s mother is an elementary teacher. CJ inherited his parents

f. Environment (home environment, accidental hazards, attitude)

g. Nutrition (likes and dislikes, amount intake, height and weight)

h. Socio- economic status (income adequate to meet basic needs)

The income of his parents is Php.22,000. Php.2,000 from his father’s

IV. DEVELOPMENTAL MILESTONES

Skin, Hair, Nails

Head and Neck

Mouth and teeth

VI. RESULT MMDST TO INCLUDE INTERPRETATION

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