Patient X is 3 months old male

born on July 24, 2022. Patient X is

currently residing at 54 Purok 2
Gibraltar, Baguio City living
together with his extended family.
He is the first child in his
family. He is a Filipino and his
religion Roman Catholic.
According to Erik Erikson
Psychosocial Theory, he is in the
stage of infancy under Trust vs.
Mistrust ages 0-18
months, the mother had been seen
caring for patient X by attending to
his needs
like changing the diaper,
breastfeeding and changing his
clothes this means that he
is totally dependent on other for
his needs. Success on this stage
means that the patient will
develop a sense of trust, if this fail
it will lead to Mistrust.
1. Psychosocial and Psychological Status
Patient X is a 24 days old male born on February 13, 2023. Patient X is currently residing at Bilibid Calutiit,
Bontoc, Mountain Province living together with his extended family. He is the first child in his family. He is a
Filipino and his religion is Roman Catholic. According to Erik Erikson Psychosocial Theory, he is in the stage
of infancy under Trust vs. Mistrust ages 0-18 months, the mother had been seen caring for patient X by
attending to his needlike changing the diaper, breastfeeding and changing his clothes this means that he is
totally dependent on other for his needs. Success on this stage means that the patient will develop a sense of
trust, if this fail it will lead to Mistrust.

2. Mental and Emotional Status

3. Patient X is conscious, cries

whenever he is hungry.
According to Jean Piaget
Cognitive
4. Development theory under
Sensorimotor of development
that in stage 1 it is through birth
until 2
5. years old, infants exclusively
use their reflexes such as
sucking and rooting, and their
cognitive
6. capabilities are only limited.
He only communicates when he
cries.
7. Patient X is conscious, cries
whenever he is hungry.
According to Jean Piaget
Cognitive
8. Development theory under
Sensorimotor of development
 that in stage 1 it is through birth
until 2
9. years old, infants exclusively
use their reflexes such as
sucking and rooting, and their
cognitive
10. capabilities are only limited.
He only communicates when he
cries.
11. Patient X is conscious, cries
whenever he is hungry.
According to Jean Piaget
Cognitive
12. Development theory under
Sensorimotor of development
that in stage 1 it is through birth
until 2
 13. years old, infants exclusively
use their reflexes such as
sucking and rooting, and their
cognitive
14. capabilities are only limited.
He only communicates when he
cries.
Patient X is conscious, cries whenever he is hungry. According to Jean Piaget Cognitive Development Theory
under Sensorimotor of Development that in stage 1 it is through birth until 2 years old, infants exclusively use
their reflexes such us sucking and rooting, and their cognitive capabilities are only limited. He only
communicates when he cries.

3. Environmental Status

15. Patient X lives in their own

house in Gibraltar together with
his mother, grandparents, and
his
16. father. The mother said that
their house is a Bungalow type
with 2 rooms with a separate
17. kitchen and she said that they
live near the road. Prior to
hospitalization the patient
18. stays at home. During the
hospitalization, Patient was
admitted at the pediatric ward
19. with good lighting, congested
due to many patients, with
student nurses, staff nurses and
20. doctors consistently
monitoring them, ward is noisy
because it is overpopulated that
even the
21. hallways were occupied just
like patient X’s bed. Even with
all the noises, the patient was
 22. able to sleep as long as his
mother is with him
Patient X lives in their own house in Bilibid Calutiit together with his mother, grandparents, and his father. The
mother said that their house is a one floor type with 2 rooms with a separate kitchen. Prior to hospitalization
the patient stays at home. During the hospitalization, Patient was admitted at the pediatric ward with good
lighting, congested due to many patients, with student nurses, staff nurses and doctors consistently monitoring
them, ward is noisy because it is overpopulated that even the hallways were occupied just like patient X’s bed.
Even with all the noises, the patient was able to sleep as long as his mother is with him.

4. Sensory Status
a. Vision
He is reactive to light, conjunctiva is pale, the sclera is white in color and no presence of discharges noted.
b. Hearing
Respond to crying of the other patient’s babies by means of waking up immediately on his deep sleep after
hearing it.
c. Smell
There is no presence of nasal flaring.
d. Taste
Good sense of taste as proven by good sucking reflex.
e. Tactile
The patient was able to differentiate common object by touch and able to discriminate light and firm touch.

5. Motor Status
Patient X was able to grasp when putting the fingers in his hands, while his feet can flex and extend.

6. Nutritional Status
The patient is purely breastfed. Prior to hospitalization the patient’s weight is 6.0 kg during course of
hospitalization his weight increased to .2 which is already 6.2 in kg.

7. Elimination Status
Prior to hospitalization, patient X’s mother stated that she changes the diaper 2-3 times per day that contains
urine only and sometimes urine and fecal that is mustard yellow or sometimes brownish in color with soft
consistency.

8. Fluid and Electrolytes Status

The source of patient’s fluid is breast milk. I received patient X with an intact heplock in his right/left arm.

9. Circulatory Status
The cardiac rate of patient X ranges from 136-156 beats per minute. During the rotation no abnormal cardiac
rate noted. The normal cardiac rate of a 1 month to 12 months old infant is 100- 190 beats per minute if awake
and 90- 160 if asleep.

March 13, 2023 Cardiac Rate

10pm 151 [ASLEEP] Normal
2am 139 [AWAKE] Normal
6am 136 [AWAKE] Normal
March 14, 2023
10pm 149 [AWAKE] Normal
 2am 143 [ASLEEP] Normal
6am 144 [AWAKE] Normal
March 15, 2023
10pm 156 [ASLEEP] Normal
2am 142 [ASLEEP] Normal
6am 155 [AWAKE] Normal

10. Respiratory System

The table below shows the patient’s respiratory rate ranging from 39-42 cycles per minute are all in normal as
30-53 cycles is the normal range for all infants below 1 year old. The oxygen saturation ranges from 95%-98%
which is in normal range were 95%-100% ae the normal value for oxygen saturation.

March 13, 2023 Respiratory Rate Oxygen Saturation

10pm 151 Normal 99% Normal
2am 139 Normal 99% Normal
6am 136 Normal 96% Normal
March 14, 2023
10pm 149 Normal 98% Normal
2am 143 Normal 99% Normal
6am 144 Normal 98% Normal
March 15, 2023
10pm 156 Normal 95% Normal
2am 142 Normal 98% Normal
6am 155 Normal 96% Normal

11. Temperature Status

During the rotation patient X is afebrile. No sign of profuse sweating noted.

March 13, 2023 Temperature

10pm 36.7 Normal
2am 36.6 Normal
6am 36.8 Normal
March 14, 2023
10pm 36.5 Normal
2am 36.6 Normal
6am 36.7 Normal
March 15, 2023
10pm 36.5 Normal
2am 36.7 Normal
6am 36.6 Normal

12. Integumentary Status

The skin is moisture and in good skin color, with normal skin turgor, and no presence of lesions and rashes
observed.

13. Rest and Sleep Pattern

Prior to hospitalization the mother said that patient X sleeps most of the time, but cries when feels hungry.
During hospitalization, he sleeps after being breastfed and he easily woke up whenever he hears noises.