Case Study 1 Final

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CASE STUDY: ADOPT A

CASE STUDY: ADOPT A CHILD
CHILD
I. SITUATIONAL ANALYSIS
This case study aims to increase the understanding and knowledge

of midwives on how to care and address problems for children with
anemia effectively and efficiently. Thorough assessment, several
home visits, and interviews with the parents of the child subjected
to this case study can provide us data on how the child developed
anemia by several aspects, how anemia progresses, describe and
identify common signs and symptoms, discuss interventions for the
its management, formulate appropriate care plans suited for the
child based on assessment findings, and identify care measures to
be given to the patient and family to promote continuity of care.
Several aspects such as nutrition, socio-economic status,
environment, life style and health practices severely affect in the
development since anemia is mostly caused by nutritional
deficiencies.
II. ASSESSMENT
A. DEVELOPMENTAL MILESTONE
Patients Profile
Name: _____________
Age: 3 y/o
Birth date: February 08, 2014
Sex: Male
Address: Sitio Cadulayan, San Luis, Pugo, La Union
1. Language Development
According to Browns Stages of Language Development, the child
is at Stage 3. The patient uses 4 or more words combined and
sentences are becoming longer. Speech is usually fluent and
clear, and other people can understand what the child is talking
about. The child can also answer questions of What, Where,
and Who.
2. Emotional Development
The child is starting to show wider range of emotions. He is
interested in pretend play, but may confuse real and make
2
CASE
believe. The child STUDY: ADOPT
is spontaneously A
caring and kind towards
CHILD
other people. He plays with other kids and separates from
parents more often. Sometimes, he still has tantrums because of
not getting what he wants.
3. Cognitive Development
The child is at the preoperational stage based on Piagets
Cognitive Stages of Development. The child is able to think
things symbolically. He also develops memory and imagination.
However, he cant still grasp more complex concepts such as
cause and effect, time, and comparison.
4. Motor Development
The child displays both normal gross and fine motor skills. The
child eats by himself, grasping pencil without tremors, and walks
without assistance.
5. Social Development
According to Erik Eriksons Theory of Psychosocial development,
the child is at the stage of Autonomy vs. Shame and Doubt. The
virtue for this stage is will and significant in the achievement of
this milestone is the mother. Toilet training is an important task.
The child is exploring and is using tools such as crayons and
pencil for making art. The child develop his first interest in the
form of playing outdoors, playing with animals and ground
games.
Developmen Normal Assessed Implication Factors

tal Finding/s s Affecting
Milestone
Language Uses 4 or Uses This stage is
Development more words basic the most
Combines words critical when
words to native to it comes to
create current language
longer ethnic development
sentences location as hearing
eg. Ako and
(I), Sika speaking
(you) problems
becomes
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CASE STUDY: ADOPT A

more
CHILD
evident.
Children of
this stage
starts to ask
questions,
sometimes
of indefinite
whys, so it
is important
to take
advantage of
this stage to
teach
children
words by
providing
them
reading
materials.
Emotional Interested Plays Children of Parenting
Development in pretend with this age who style
play siblings are passive
Kind and Cries and and fearful
caring tantrums need
towards when not attention
playmates getting from a
Becomes what he mental
less wants health
egocentric professional.
Cognitive Develops Choose 5 A delay on Parenting
Development imagination pieces of this stage of style
and 1 peso cognitive Socio-
memory coin development economi
Learns rather may indicate c status
through than a 1 learning
pretend five peso disabilities.
play but still coin to Presence of
struggle play with a learning
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CASE STUDY: ADOPT A

with logic Sorts disability
CHILD
objects greatly
by shape affects ones
and color development
from toddler
towards
adulthood.
Motor Presence of Copies If this Nutrition
Development self-care circle milestone is Early
skills such Imitates not detection
as eating cross achieved, of
Doing of Eating the child will genetic
pencil- without have poor diseases
based tasks assistanc self-care and by NBS
Have e grasping
drawing Turns skills. A
skills pages of delay on this
books stage may
Walks indicate
without neuromuscul
assistanc ar
e dysfunction
as well.
Social Gains Picks A delay on Parenting
Development independen what to this stage style
ce wear makes the Presence
Decides on Puts his child feel of
his own own ashamed, playmate
Goes tom clothes insecure, s
toilet alone Decides and doubting Level of
what he about his restrictio
wants to self. n
eat
Chooses
toy cars
as his toy
preferenc
e
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CASE STUDY: ADOPT A

CHILD
B. MEDICAL HISTORY
1. History of Past Illnesses

Two years ago, the child was confined at La Union Medical Center
due to Community Acquired Pneumonia. September 7, 2015, the
parents and the child seek medical consultation at Pugo Rural
Health Unit PTA at LUMC. According to the patients record, the
child presented coughing for 10 days, temperature of 38.6 C,
RR 42 cpm, PR 137 bpm, (+) crackles, (+) wheezing, (+) chest
indrawing, and mild dehydration as manifested by poor skin
turgor and sunken eyeballs. Since the RHU doesnt have
intravenous lines, the MHO advised the parents of the child to go
to LUMC, hence, the admission. The child was confined 12 days
at LUMC and was successfully treated.
Last October 2016, the child was given Albendazole as part of
yearly deworming activity of Pugo RHU, and worms came out of
his anus as well.
One month prior to visit at their residence, the child was again
confined at Rosario District Hospital due to Acute Gastroenteritis.
According to the parents of the child, he had diarrhea, vomiting,
fever, and his weight also decreased. The child was also
observed to be pale and have a sore tongue. He undergone blood
laboratory works and was revealed that he also has anemia. The
child was given intravenous fluids, antiemetics, and
metronidazole. Discharge instructions include fluid and
electrolytes replenishment and follow up consultation.
2. History of Present Illnesses

Upon admission at LUMC one month ago, the child was
diagnosed with Acute Gastroenteritis, and blood laboratory works
revealed he has anemia with Hgb: 10.2 g/dL, Hct: 29%, RBC: 3.7
6
x 10 /L. Prior to admission, the child presented shortness of
breath, some palmar pallor, getting tired easily and eating less.
3. Newborn History
The patient was born on February 8, 2014 at Rosario District
Hospital, with Apgar score: 8, BW: 3.5 kgs. He was given BCG and
Hep B vaccine same day. Heel-prick testing was also done as part
of newborn screening test. No genetic disorders were diagnosed.
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CASE STUDY: ADOPT A

CHILD
C. NUTRITIONAL STATUS
1. Anthropometric Data
Anthropomet Normal Assesse Implication

ric Data Range d
Weight 12-14 11.8 kg Measurement of weight is important to
kg measure growth of a child. Abnormal weight
may signify malnutrition, metabolic
disorders, and cardiovascular problems.
Height/Length 85-95 87 cm Measurement of height is important to

cm measure growth of a child. Slow or fast
growth rate may indicate genetic,
endocrine, and neuromuscular problem.
Body Mass 18.5 15.6 A body mass index in the low range signals
Index or 24.9 that you could be malnourished. Maybe
Weight For your body isnt properly absorbing nutrients
Height or or maybe youre just not getting enough
calories to support your activity level.
Weight For
Conversely, having a BMI on the higher end
Length
alerts your physician that your risks of
heart disease, diabetes and certain cancers
are higher than someone with a normal
BMI.
Mid-Upper Arm 125 126 A MUAC lower than 125 may indicate acute
Circumference mm malnutrition. MUAC of 110 mm indicates
and severe malnutrition.
above
2. Dietary History
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CASE STUDY: ADOPT A

Date/D Food Intake Factors
Time CHILD Implication/s
ay Food Quantity Affecting
January Breakfa Powdered 1 cup, Skipping breakfast Financial
16, st milk, sweet 2 small can make toddlers status
2017 (Time) potato pcs feel tired, restless, or Parenting
irritable. In the style
morning, their bodies
need to refuel for the
day ahead after
going without food
for 8 to 12 hours
during sleep. Their
mood and energy can
drop by midmorning
if they don't eat at
least a small morning
meal.
Snacks Bread 2 slices Snacks between Financial
(Time) major meals prevent status
the toddlers to lose Parenting
concentration and style
provide energy
during physical
activities.
Food is of no iron
content.
Lunch Rice 1 cup Eating in the middle Financial
(Time) Mongo of the day, several status
hours after breakfast, Parenting
re-energizes body style
and can raise blood
sugar levels when
focus and
concentration are
flagging.
Food is of high iron
content.
Snacks Lugaw 1 cup Snacks between Financial
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CASE STUDY: ADOPT A

CHILD
provide energy
during physical
activities.
Food is of low iron
content.
Dinner Rice 1 cup Eating right amount Financial
(Time) Hotdog 2 pcs of dinner is important status
so as not to get Parenting
famished during style
sleep. Too much
eating at night
causes obesity,
especially to children
since during night
time, metabolic rate
is slow.
Midnigh N/A N/A N/A N/A
t
Snacks
(Time)
January Breakfa Champorad 1 cup Skipping breakfast Financial
23, st o can make toddlers status
2017 (Time) feel tired, restless, or Parenting
day ahead after
going without food
for 8 to 12 hours
during sleep. Their
mood and energy can
drop by midmorning
meal.
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CASE STUDY: ADOPT A

Food is of low iron
CHILD
content.
Snacks Cup cake 1 pc Snacks between Financial
(Time) Juice 1 major meals prevent status
tetrapack the toddlers to lose Parenting
provide energy
during physical
activities.
Food is of no iron
content.
(Time) Hotdog 2 pcs of the day, several status
and can raise blood
sugar levels when
focus and
concentration are
flagging.
Food is of low iron,
high preservative
content.
Snacks Sweet 1 big pc Snacks between Financial
(Time) potato major meals prevent status
provide energy
during physical
activities.
Food is of no iron,
high calorie content.
(Time) Instant of dinner is important status
noodles so as not to get Parenting
sleep. Too much
eating at night
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CASE STUDY: ADOPT A

causes obesity,
CHILD
since during night
is slow.
Food is high in salt,
preservative, no iron
content.
t
Snacks
(Time)
January Breakfa Lugaw 1 small Skipping breakfast Financial
30, st bowl can make toddlers status
day ahead after
going without food
for 8 to 12 hours
during sleep. Their
mood and energy can
drop by midmorning
meal.
Food is of high
calorie, low iron
content.
Snacks Macaroni 1 cup Snacks between Financial
(Time) soup major meals prevent status
provide energy
during physical
activities.
Food is of moderate
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CASE STUDY: ADOPT A

iron, high calorie, and
CHILD
high calcium content.
(Time) Fried fish 1 pc of the day, several status
and can raise blood
sugar levels when
focus and
concentration are
flagging.
Food has moderate
iron, high protein
content.
Snacks Lumpia 2 pcs Snacks between Financial
provide energy
during physical
activities.
low micronutrient
content.
(Time) Fried egg 1 pc of dinner is important status
so as not to get Parenting
sleep. Too much
eating at night
causes obesity,
since during night
is slow.
Food is of no iron
content.
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CASE STUDY: ADOPT A

t
CHILD
Snacks
(Time)
Februar Breakfa Fried rice 1 cup Skipping breakfast Financial
y 7, st Fried egg 1 pc can make toddlers status
day ahead after
going without food
for 8 to 12 hours
during sleep. Their
mood and energy can
drop by midmorning
meal.
Food is of high
calorie, high
saturated fat, and
low iron content.
Snacks Puto 5 small Snacks between Financial
(Time) Fruit Juice pcs major meals prevent status
1 the toddlers to lose Parenting
tetrapack concentration and style
provide energy
during physical
activities.
moderate
micronutrient
content.
Lunch Rice I cup Eating in the middle Financial
(Time) Mongo of the day, several status
and can raise blood
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CASE STUDY: ADOPT A

sugar levels when
CHILD
focus and
concentration are
flagging.
Food has moderate
iron, high protein
content.
Snacks Boiled I pc Snacks between Financial
(Time) banana I major meals prevent status
Juice tetrapack the toddlers to lose Parenting
provide energy
during physical
activities.
moderate
micronutrient
content.
Dinner Rice I cup Eating right amount Financial
(Time) Chicken 1 slice of dinner is important status
stew so as not to get Parenting
sleep. Too much
eating at night
causes obesity,
since during night
is slow.
Food is of high iron
content.
t
Snacks
(Time)
D. Physical Assessment
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CASE STUDY: ADOPT A

CHILD
Body Factors
Normal Finding/s Assessed Implication/s
Parts Affecting
Skin When skin is Palm looks pale Palm looks pale Environment
pinched it goes to Skin is dry due to temperature
previous state inadequate
immediately (2 oxygen supply
seconds). With fair to other parts of
complexion. the body. RBC
carries
hemoglobin. Hgb
carries oxygen
towards different
parts of the
body.
Skin is dry due
to insufficient
fluid intake.
Generally round, Normal findings The child should
Skull with prominences seek immediate
in the frontal and consultation if
occipital area. there is
(Normocephalic). concussion.
No tenderness
noted upon
palpation
Scalp Lighter in color Normal findings Presence of Presence/Absenc

than the infestations, e of infestations
complexion. Can be such as lice, is
moist or oily. an indicator of
No scars noted. poor hygienic
Free from lice, nits practices.
and dandruff. No
lesions should be
noted. No
tenderness or
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CASE STUDY: ADOPT A

masses on
CHILD
palpation.
Hair Can be black, Hair is coarse Hair is coarse Nutrition

brown or burgundy and dry and dry because Environmental
depending on the of inadequate temperature
race. Evenly micronutrient
distributed covers supply, such as
the whole scalp vitamin E, to
No evidences of hair cells. Dry
Alopecia. Maybe hair indicates
thick or thin, inadequate
coarse or smooth. hydration.
Neither brittle nor
dry.
Eye Symmetrical and in Normal findings

Brows line with each
other. Maybe black,
brown or blond
depending on race.
Evenly distributed.
Eyes Evenly placed and Eyelids are pale Eyelids look pale
in line with each bilaterally. bilaterally due to
other. None inadequate
protruding. Equal oxygen supply
palpebral fissure. to other parts of
the body. RBC
carries
hemoglobin. Hgb
carries oxygen
towards different
parts of the
body.
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CASE STUDY: ADOPT A

Eyelashes Color dependent on Normal findings
CHILD
race. Evenly
distributed. Turned
outward.
Ears The ear lobes are Normal findings Abnormal

bean shaped, findings may
parallel, and indicate hearing
symmetrical. The disorders and
upper connection balancing
of the ear lobe is problems, such
parallel with the as otitis.
outer canthus of
the eye. Skin is
same in color as in
the complexion. No
lesions noted on
inspection. The
auricles are has a
firm cartilage on
palpation. The
pinna recoils when
folded. There is
no pain or
tenderness on the
palpation of the
auricles and
mastoid process.
The ear canal has
normally some
cerumen of
inspection.
No discharges or
lesions noted at the
ear canal. On
otoscopic
examination the
tympanic
membrane appears
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CASE STUDY: ADOPT A

flat, translucent
CHILD
and pearly gray in
color.
Nose Nose in the Normal findings Nasal flaring

midline. No except the indicates
Discharges. No presence of shortness of
flaring. Both nares nasal flaring breath. Presence
are patent. No when exhausted. of yellow,
bone and cartilage brownish or
deviation noted on greenish
palpation. No discharge
tenderness noted indicates
on palpation. Nasal infection.
septum in the mid Increased
line and not redness
perforated. The turbinates are
nasal mucosa is typical of allergy.
pinkish to red in
color. No
tenderness noted
on palpation of the
paranasal sinuses.
Mouth With visible margin Normal findings

Symmetrical in
appearance and
movement Pinkish
in color No edema
Gums Pinkish in color No Gums are slightly Gums are

gum bleeding pinkish in color slightly pinkish
No receding gums due to
inadequate
oxygen supply
to other parts of
the body. RBC
carries
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CASE STUDY: ADOPT A

hemoglobin. Hgb
CHILD
carries oxygen
towards different
parts of the
body.
Teeth 28 teeth
White to yellowish
in color With or
without dental
carries and/or
dental fillings. With
or without
malocclusions. No
halitosis.
Tongue Pinkish with white

taste buds on the
surface. No lesions
noted. No
varicosities on
ventral surface.
Frenulum is thin
attaches to the
posterior 1/3 of the
ventral aspect of
the tongue. Gag
reflex is present.
Able to move the
tongue freely and
with strength.
Surface of the
tongue is rough.
Nails The client has a Nailbeds have Slow capillary

light brown nails slow capillary refill is a sign of
and has the shape refill, 5 seconds. anemia.
of convex curve. It Nails are soiled.
is smooth and is
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CASE STUDY: ADOPT A

intact with the
CHILD
epidermis. When
nails pressed
between the
fingers (Blanch
Test), the nails
return to usual
color in less than 3
seconds.
Neck The neck is Normal findings

straight. No visible
mass or lumps.
Symmetrical No
jugular venous
distension
(suggestive of
cardiac
congestion). The
neck is palpated
just above the
suprasternal note
using the thumb
and the index
finger.
Abdomen Skin color is Normal findings Position upon

uniform, no lesions. except there is assessment
Some clients may presence of
have striae or scar. hyperactive
No venous bowel sounds
engorgement. upon
Contour may be auscultation on
flat, rounded or lower quadrants
scaphoid Thin of the abdomen.
clients may have
visible peristalsis.
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CASE STUDY: ADOPT A

Extremiti Both extremities Normal findings
CHILD
es are equal in size. Scars present at
Have the same right knee and
contour with left elbow.
prominences of
joints. No
involuntary
movements. No
edema Color is
even. Temperature
is warm and even.
Has equal
contraction and
even. Can perform
complete range of
motion. No crepitus
must be noted on
joints. Can counter
act gravity and
resistance on ROM.
E. Vital Signs
Date RR PR T BP Implication/s
January 16, 40 120 36.7 N/A The normal body temperature of a person
2017 varies depending on gender, recent
activity, food and fluid consumption, time
of day. The child may not have adequate
carbohydrate and fluid consumption.
Body temperature may be abnormal due
to fever (high temperature)
or hypothermia (low temperature).
Respiration rates may increase with fever,
illness, and with other medical conditions.
The pulse rate is a measurement of the
heart rate, or the number of times the
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CASE STUDY: ADOPT A

heart beats per minute. As the heart
CHILD
pushes blood through the arteries, the
arteries expand and contract with the
flow of the blood. Taking a pulse not only
measures the heart rate, but also can
indicate heart rhythm and strength of the
heartbeat.
January 23, 41 117 36.0 N/A The normal body temperature of a person
heartbeat.
January 30, 38 99 36.9 N/A Body temperature may be abnormal due

2017 to fever (high temperature)
or hypothermia (low temperature). A
fever is indicated when body temperature
rises about one degree or more over the
normal temperature. Respiration rates
may increase with fever, illness, and with
other medical conditions. The pulse rate
is a measurement of the heart rate, or
the number of times the heart beats per
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CASE STUDY: ADOPT A

minute. As the heart pushes blood
CHILD
through the arteries, the arteries expand
and contract with the flow of the blood.
Taking a pulse not only measures the
heart rate, but also can indicate heart
rhythm and strength of the heartbeat.
February 7, 38 97 36.0 N/A The normal body temperature of a person

heartbeat.
F. Immunization Status
Immunization/Vacc Date Given Implication/s

ine
Bacillus CalmetteGurin (BCG) vaccine is
BCG 2-8-14 a vaccine primarily used
against tuberculosis. In countries where
tuberculosis is common, one dose is
recommended in healthy babies as close to
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CASE STUDY: ADOPT A

the time of birth as possible. Tentative
CHILD
evidence exists for a beneficial non-specific
effect of BCG vaccination on overall
mortality, or for its reducing other health
problems including sepsis and respiratory
infections when given early, with greater
benefit the earlier it is used.
Hep B vaccination is the best way to protect

Hepatitis B 2-8-14 against hepatitis B. The vaccination also
Protects other people from the disease
because children with hepatitis B usually
dont have symptoms, but they often pass
the disease to others without anyone
knowing they were infected. Prevents your
child from developing liver disease and
cancer from hepatitis B.
OPV vaccine prevents polio, pentavalent

Penta 1, OPV 1 3-24-14 vaccine is a combined vaccine with five
individual vaccines conjugated into one,
intended to actively protect people from 5
potentially deadly diseases. The main
example is a vaccine that protects
against Haemophilus Influenza type
B, whooping cough, tetanus, hepatitis
B and diphtheria.

B and diphtheria.
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CASE STUDY: ADOPT A

CHILD
B and diphtheria.
This vaccine prevents measles, preventing

Measles 11-12-14 development of high grade fever and
uncomfortable rashes.
This vaccine prevents measles, mumps and

MMR 04-18-15 rubella, preventing development of high
grade fever and uncomfortable rashes.
III. Diagnosis
A. List of Problems and Prioritization
List of Health Prioritization Ran Justification

Problem/s Criteria k
Imbalanced Maslows 1 This diagnosis receives the highest priority
Nutrition: Less Hierarchy of because solving this problem would also help
than Body Needs other problems the child is experiencing such
Requirements as fatigue and altered tissue perfusion due to
r/t inadequate low iron content.
intake of
essential
nutrients
Level 1 Activity Maslows 3 This problem is the least priority since it

Intolerance Hierarchy of solution of the first two problems would help
related to Needs address solution to this problem. The parents
imbalance can also help in ADLs of the child.
between oxygen
supply and
demand
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CASE STUDY: ADOPT A

Ineffective tiss Maslows 2 This problem receives second priority because
ue Hierarchy of it isCHILD
oxygenation that is the problem.
perfusion relat Needs
ed to
insufficient
hemoglobin
and
hematocrit
IV. Health Care Plan
HEALTH CARE PLAN
Heath Problem 1: Imbalanced Nutrition: Less than Body Requirements r/t inadequate intake of essential nutrients
Assessment Objectives Health Care Interventions Rationale Evaluation

STO:
Subjective Data: STO: Diagnostic: 1. These anthropomorphic
Konte lang kinakain ng 1. Measure weight and never assessments are vital that they Within 8 hours of
anak ko, di niya masyado Within 8 hours of estimate. need to be accurate. These will be effective health care
used as basis for caloric and intervention:
gusto gulay. As effective health care
verbalized by his mother intervention: nutrient requirements. 1. Parents were
1. Parents will able to
present present
2. Take a nutritional history with the
understanding participation of SO. understandin
2. Family members may provide
of significance more accurate details on the g of
Objective Data: of nutrition to significance
feeding habits of the child.
(+) Dry, brittle, hair healing of nutrition to
3. Look for physical signs of
easily plucked from process and poor nutritional intake. healing
3. Manifestations are brittle hair, pale
scalp general health. process and
palpebral sac, and dry skin.
general
health.
(+) Hyperactive 2. Parents will
bowel sounds verbalize and Therapeutic:
demonstrate Independent 2. Parents were
selection of able to
foods or meals 4. Provide companionship
(+) Pale, dry skin verbalize and
that will during mealtime. 4. Attention to the social demonstrate
accomplish a perspectives of eating is important selection of
Weight: 11.8 kg termination of 5. Provide good oral hygiene. in home settings. foods or
(below normal range) weight loss. meals that
will
5. Oral hygiene has a positive effect accomplish a
on appetite and on the taste of termination of
6. Determine the time of day when
food. weight loss.
LTO: the childs appetite is at peak.
Offer him highest calorie, highest
iron content meal at that time.
After 72 hours of 6. Children have peak appetite during
effective health care snacks and lunch time.
intervention, LTO:
1. Patient will
display Dependent After 72 hours of
nutritional effective health care
7. Administer multivitamins syrup
ingestion intervention,
following a physicians
sufficient to prescription. 1. Patient was
meet able to
metabolic display
8. Administer ferrous sulfate syrup 7. Multivitamin supplements suffice
needs as 1.5 tsp OD as per doctor's order, micronutrient intake insufficiencies nutritional
manifested by with orange juice. through foods. ingestion
stable weight sufficient to
or muscle- meet
mass Collaborative 8. Vitamin C found in orange juice metabolic
facilitates absorption of iron enterally.
measurements 9. Inquire to a nutritionist about needs as
Nutritional Facts label on manifested by
2. Patient maintai packaged foods.
ns weight or stable weight
displays or muscle-
weight gain on mass
9. To have a more detailed dietary measurement
the way to advisory
preferred goal. s
Educative:
2. Patient
10. Inform parents about foods high
in iron such as chicken liver, fish,
displayed
beans and green leafy weight gain
vegetables. on the way to
preferred
11. Discourage carbonated drinks
goal.
and juice concentrates and 10. Lot of iron containing foods are of low
encourage increase water intake. cost.
12. Encourage verbalization of

inquiries.
11. Carbonated drinks and juice
concentrates contain high amounts of
sugars.
12. This is to have a smart and practical

selection of foods.
Heath Problem 2: Ineffective tissue perfusion related to insufficient hemoglobin and hematocrit secondary to anemia

STO:
Subjective Data: STO: Diagnostic: Within 8 hours of
effective health care
"Maputla anak ko." as Within 8 hours of 1. Assess for signs for decreased tissue Initial assessment provides a baseline for future
intervention:
verbalized by the mother. effective health perfusion. comparison.
care intervention: 1. Parents of the child
identified necessary
1. Parents of the 2. Check respirations and its pattern. 2. Anemic patients usually have increased RR to lifestyle changes.
child identifies compensate for low oxygen level in the blood.
necessary
lifestyle 3. Low levels reduce the uptake of oxygen at
3. Check for laboratory data (Hgb and 2. The child engaged in
Objective Data: changes. alveolar-capillary membrane.
Hct). behaviors or actions
(+) shortness of breath to improve tissue
perfusion.
2. The child Therapeutic:
engages in
Capillary refill: 5 seconds behaviors or Independent
actions to Exercise prevents further circulatory compromises. LTO:
4. Promote active and passive ROM
improve tissue exercises. After 72 hours of
(+) pale palpebral sac perfusion. effective health care
intervention, patient
along conjunctiva
5. Offer optimal fluid intake. Sufficient fluid intake maintains adequate filling maintains maximum
LTO: pressures and optimizes cardiac output. tissue perfusion to vital
organs as evidenced by
Hgb: 10.2 g/dL After 72 hours of
capillary refill of 3
effective health 6. Provide rest periods between care Constant activity can exhaust the patient. seconds, and improved
care intervention, activities. respiratory rates.
Hct: 29% patient maintains
maximum tissue .
perfusion to vital
organs. 7. Position patient in semi-Fowler's or Upright positioning promotes improved alveolar
high Fowler's as tolerated. gas exchange.
.
Dependent
8. Administer ferrous sulfate syrup 1.5 Ferrous sulfate provides iron to RBCs, thus,
tsp OD as per doctor's order. improving its capacity to carry oxygen.
Educative: Knowledge of causative factors provides a
rationale for treatments.
9. Provide knowledge on normal tissue
perfusion and possible causes of
impairment.
Early assessment facilitates immediate

10. Teach parents to recognize signs treatment.
and symptoms that need to be
reported.
Malnutrition contributes to anemia, which

11. Educate parents about nutritional further compounds lack of oxygenation.
status and importance of paying
special attention to malnutrition.
12. Encourage smoking cessation. Smoking tobacco is associated with

catecholamines release resulting in
vasoconstriction and decreased tissue perfusion.
Heath Problem 3: Level 1 Activity Intolerance related to imbalance between oxygen supply and demand
Subjective Data: STO: Diagnostic: STO:

"Madali mapagod anak 1. Take resting vital signs and 1. Provides baseline information.
ko.", as verbalized by the immediately after an activity.
Within 8 hours of Within 8 hours of
mother effective health effective health care
care intervention: intervention:
2. Assess patient's nutritional status. 2. Adequate energy reserves are needed during
1. The parents of 1. The parents of the
the activity.
the patient will patient were able to
Objective Data: be able to identify factors that
identify factors 3. Observe and document response to 3. Close monitoring will serve as a guide for aggravate activity
Often asleep that aggravate activity. optimal progression of activity intolerance.
activity
intolerance.
Therapeutic: 2. The parents of the
irritable at times patient were able to
2. The parents of Independent identify methods to
the patient will 1. Have the child perform activities 1 Helps in increasing the tolerance for the activity. reduce activity
(+) shortness of breath be able to more slowly with more rest and intolerance
identify pauses, or with assistance if
methods to necessary.
reduce activity LTO:
intolerance
2. Gradually increase activity with 4. Gradual progression of activity prevents
active ROM exercises. overexertion. After 72 hours of
LTO: effective health care
intervention,
3. Refrain from performing 5. Patient with limited activity tolerance need to the patient exhibited
After 72 hours of nonessential activities. prioritize important task first. tolerance during
effective health physical activity.
care intervention,
4. Reward patient in an accomplished 6. Promotes cooperation during the visit.
the patient will
exhibit tolerance task.
during physical
activity.
Dependent
1. Administer multivitamins syrup 1.5 1 Multivitamins help prevent depletion of other
tsp as per doctor's order. micronutrients essential for blood.
Educative:
1 Instruct parents to plan activities for 1. Activities should be planned ahead to coincide
times when the child's energy is at with patients peak energy level.
peak.
5. Teach parents to recognize signs of 2 So as to know when to seek consultation.

overexertion.

Case Study 1 Final

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1

CASE STUDY: ADOPT A

This case study aims to increase the understanding and knowledge

Developmen Normal Assessed Implication Factors

CASE STUDY: ADOPT A

CASE STUDY: ADOPT A

CASE STUDY: ADOPT A

1. History of Past Illnesses

2. History of Present Illnesses

CASE STUDY: ADOPT A

Anthropomet Normal Assesse Implication

Height/Length 85-95 87 cm Measurement of height is important to

CASE STUDY: ADOPT A

CASE STUDY: ADOPT A

CASE STUDY: ADOPT A

CASE STUDY: ADOPT A

CASE STUDY: ADOPT A

CASE STUDY: ADOPT A

CASE STUDY: ADOPT A

CASE STUDY: ADOPT A

Scalp Lighter in color Normal findings Presence of Presence/Absenc

CASE STUDY: ADOPT A

Hair Can be black, Hair is coarse Hair is coarse Nutrition

Eye Symmetrical and in Normal findings

CASE STUDY: ADOPT A

Ears The ear lobes are Normal findings Abnormal

CASE STUDY: ADOPT A

Nose Nose in the Normal findings Nasal flaring

Mouth With visible margin Normal findings

Gums Pinkish in color No Gums are slightly Gums are

CASE STUDY: ADOPT A

Tongue Pinkish with white

Nails The client has a Nailbeds have Slow capillary

CASE STUDY: ADOPT A

Neck The neck is Normal findings

Abdomen Skin color is Normal findings Position upon

CASE STUDY: ADOPT A

CASE STUDY: ADOPT A

January 30, 38 99 36.9 N/A Body temperature may be abnormal due

CASE STUDY: ADOPT A

February 7, 38 97 36.0 N/A The normal body temperature of a person

Immunization/Vacc Date Given Implication/s

CASE STUDY: ADOPT A

Hep B vaccination is the best way to protect

OPV vaccine prevents polio, pentavalent

OPV vaccine prevents polio, pentavalent

CASE STUDY: ADOPT A

This vaccine prevents measles, preventing

This vaccine prevents measles, mumps and

List of Health Prioritization Ran Justification

Level 1 Activity Maslows 3 This problem is the least priority since it

CASE STUDY: ADOPT A

HEALTH CARE PLAN

Assessment Objectives Health Care Interventions Rationale Evaluation

12. Encourage verbalization of

12. This is to have a smart and practical

Assessment Objectives Health Care Interventions Rationale Evaluation

Early assessment facilitates immediate

Malnutrition contributes to anemia, which

12. Encourage smoking cessation. Smoking tobacco is associated with

Assessment Objectives Health Care Interventions Rationale Evaluation

Subjective Data: STO: Diagnostic: STO:

5. Teach parents to recognize signs of 2 So as to know when to seek consultation.

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