Neonatal Assessment

Demographic Data

Name:

A.D

Address:

CHRV Ph2 Blk 58 Lt 43 Langkaan2, Dasmarias Cavite

Age:

25 years old

Sex:

Female

Date of Birth:

August 11, 1987

Place of Birth:

Manila

Civil Status:

live in

Religion:

Catholic

Education:

High School Undergraduate

Occupation:

None

Monthly Income:

None

II

Reasons for Seeking Health Care:

Neonatal assessment

III

History of Present Illness

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VII.

GORDONS FUNCTIONAL HEALTH PATTERN

Nutritional Metabolic
She eats vegetables and meat. She have well balanced diet. She
takes 8to10 glass of water every day. She is also taking vitamins
like ferrous sulfate. Before sleeping, she drinks milk for calcium of
the baby.

3 Day Diet Recall

Meals
Breakfast

August 21
1 egg and
hotdog
2-3 cups rice
1 cup of milk

August 22
1egg

August 23
1 egg and tuyo

2-3 cups rice

1 cup of milk

2-3 cups rice

1 cup of milk

Lunch

2-3 cups of
rice
2 pcs. Chicken
4 glass water

2-3 cups of
rice
Vegetables
3 glass water

2-3 cups of
rice
2 pcs. Chicken
2 glass water

Snack

1 biscuit
1 glass milo

1 biscuit
1 glass milo

1 biscuit
1 glass milo

Dinner

2-3 cups rice

1 pc. Fish
3 glass water 1
cup of milk

2-3 cups rice

1 pc. Fish
4 glass water
and 1 cup of
milk

2-3 cups rice

1 pc. Fish
1 glass water
and 1 cup of
milk

Total:

6-9 cups rice

1 pc. chicken
8to10 glasses
of water
2 glass of milk
1 biscuit

6-9 cups rice

1 pc. chicken
8to10 glasses
of water
2 glass of milk
1 biscuit

6-9 cups rice

1 pc. Chicken
8-10 glasses
of water
2 glass of milk
1 biscuit

Elimination
According to the client she had Brownish colored stool and eliminates
twice a day. Her urine color was yellow. Client said that she urinates a lot.
Client said that sometimes she urinates every 5mins after fluid intake.
Parang puno lagi pantog ko as verbalized by patient.

Activity Exercise
Client does household chores like washing and cleaning every day. Client
spends her time just resting daily. Client also prepares things for her 1 st
child.
7 day Activity Table

Time

August
17

August
18

August
19

August
20

August
21

1 am
2 am
3 am
4 am
5 am
6 am
7 am
8 am
9 am
10 am
11 am
12pm
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
11 pm
12 am
Activities of Daily Living
Activities
Bathing
Dressing
Toileting
Transferring
Continence
Feeding
Total points: 6 points

August
22

August
23

Key:
Sleep
= Yellow
Rest =
Green
Eat=
purple

Independence= 1 point
1
1
1
1
1
1

Dependence= 0 point
0
0
0
0
0
0

Sleep-Rest

The client have a problem in sleeping because every few minutes she gets
urinated. Lagi akong naiistobo sa pag tulog ko dahil sa pag ihi ko as
verbalized by client The client sleeps 10 hours a day from 9pm to 7am.

Cognitive-Perceptual

Self-Perception
She is afraid because of the pain of delivering the baby. She has a
negative attitude toward her pregnancy because of worrying about the
outcome.

Role relationship
She is single live in and pregnant. She is comfortable in her family and
showing concern regarding the child.

Sexuality
Client is pregnant. She has no partner in her child bearing.

Coping stress
She usually deals with stress by crying.

Value belief
The client is a catholic. She performs her religious practices by praying.
She believes in albularios and some religious practices.

Physical Examination
PARTS
Skin

TECHNIQUE
Inspection
Palpation

Hair

Inspection
Palpation

Nails

Inspection
Palpation

OBJECTIVE
dark in color
no lesions
Warm to touch
Dry skin
Good skin turgor
Thin
No lice
Dry and oily
No masses
Pinkish brown
in color
Smooth

FINDINGS
Normal
Normal
Normal
Normal
Normal
Normal

Palpation

Good capillary
refill
Norm cephalic
Aligned facial
features
No nodules
No masses
Aligned
Intact eyelids
Same color w/
the facial skin
Symmetric
Smooth
Elastic
No tenderness
Symmetric
No nasal flaring
No masses
no tenderness
Brownish in
color
Symmetric
No lesions
No masses

Lymph nodes
Trachea

Palpation
Palpation

Not palpable
Midline position

Normal
Normal

Thorax and
Lungs

Inspection

Symmetric

Normal

Auscultation

No adventitious
sound
Symmetrical
chest
Normal heart
sounds
Round
No lesions
w/ bowel
sounds and
heart tone of
baby.
No tenderness
and masses
with baby
inside.
Symmetric

Normal

Skull and face

Inspection

Palpation
Eyes and
vision
Ears and
hearing

Inspection
Inspection

Palpation

Nose and
sinuses

Inspection
Palpation

Mouth and
oropharynx
Neck

Inspection
Inspection

Palpation
Heart

Auscultation

Abdomen

Inspection
Auscultation

Palpation

Extremities

Inspection

Normal

Normal
Normal
Normal

Normal

Normal
Normal
Normal
Normal
Normal

Normal
Normal
Normal
Normal

Normal

Normal

No swelling
Presence of
discharge
Dental Care: with dentures and lost teeth.