Angela Rose B.

Cudia
2NUR3
RLE 2

Pediatric Care Record

Name: Angelica Tarlac

Nickname preferred:
Age: 3 months old
Grade in school: N/A
Address: Blk 10 Lot 7 Tanigue Sammatad D.D., Caloocan City
Father's Age: N/A Occupation: N/A
Mother's Age: 17 years old Occupation: N/A
Number of other siblings and their ages: N/A

Chief Complaint: LBM, cough and cold

Admitting Diagnosis: Acute gastroenteritis with moderate dehydration, Pertussis,

Malnutrition

Present Illness
Signs and Symptoms of Illness? Diarrhea
Past Illness: N/A

Review of Systems

Integumentary
Presence of mosquito bites
Skin turgor normal

Eyes, Ears, Nose, and Throat:

Pink conjunctiva
Clean cornea lids

Cardiorespiratory:
Symmetrical chest expansion
Rales, crackles

Gastrointestinal/ Nutritional
Malnourished
Breastfed
4-10 liquid stools per day

Genitourinary
Normal frequency of urine
Neurology
Conscious
Irritable
Follows sound
(+) gag reflex
Turns head
Shrug shoulder
(+) Babinski reflex

Musculoskeletal
Unpalpable posterior fontanel
Palpable anterior fontanel
Normal coordination

Senses
unremarkable

If Infant & young toddler, include developmental milestones assessment:

Head Control - 2 mos
Turned to Sides __mos N/A
Rolled-over __mos N/A
Sat with support __mos N/A
Sat alone __mos N/A
Crawled/ creep __mos N/A
Stood with support __mos N/A
Stood alone __mos N/A
Cruised __mos N/A
Walked with support __mos N/A
Walked alone __mos N/A
What can the child do now other than those above?

Extend head on prone: 2 mos

Responsive smile: 2.5 mos
Grasps and shakes: 3 mos

What can you say about the above developmental milestone of your patient?

My patient experiences a normal developmental milestone. A 3-month old starts to

grasp and shakes an object and as what her mother said, she was already able to grasp
her mothers shirt during breastfeeding. Another is the infants ability to lift her head up
while in a prone position.
 Three Developmental Theories

Erikson Freud Piaget

Trust Vs. Mistrust Oral Sensorimotor
The patient will develop The patient is in oral stage The patient learns through
mistrust, wherein the infant as what her age indicates. In sensation. Moreover,
would be fearful and this series of psychosexual repetitive behavior would be
suspicious of the world and stage, the mouth of the infant evident. But the main
people because the care for receives stimulation and achievement would be object
the infant is inadequate. pleasure. The main task of permanence. Whereas the
Although there is a the infant is to recognize the object still exists even if its
consistency of rendered important person for them, hidden.
care, consistency and which is the mother or a
effectiveness of care must besubstitute and fears
balanced in order to achieve separation.
trust If unsatisfied, the infant is
most likely to develop long-
term dependency or
aggression. This is what oral
fixation such as, drinking,
nail biting, finger chewing,
thumb sucking, and smoking,
signifies.

Laboratory tests and implication/s of the abnormality

Test Result Normal Value Implication

Fecalysis
Color: Green Brown Severe diarrhea (bile)
E.coli cyst: present None Bacterial infection
RBC: few None Bleeding in the digestive
tract
Pus: few None
Invasion of microorganisms

Medical Intervention (drugs and procedures) ordered, implication to the condition and
your nursing responsibility

Intervention Implication Nursing Responsibility

Dextrose 5% and 0.3% Maintains acid-base Monitor IV fluid and route of
NaCl IV fluid balance, isotonicity, and administration
electrophysiologic balance Monitor fluid
throughout body tissues; Observe for IV complication
crucial to nerve impulse
transmission and con-
traction of cardiac, skeletal,
and smooth muscle. Also
essential for nor- mal renal
function and carbohydrate
metabolism.

Drug action

Erythromycin Binds with 50S subunit of Give health teachings as

susceptible bacterial well as the proper time of
ribosomes, suppressing administration
protein synthesis in Side effects
bacterial cells and causing
cell death