M.Sc. Nursing Care Plan For Special Group

1. COMMUNITY HEALTH NURSING
SUBMITTED TO - SUBMITTED BY-
MRS. MALLIKA ROY MR. DEEPAK P. GAUTAM
ASSISTANT PROFESSOR MSC NSG 1ST
YEAR
R.D. MEMORIAL COLLEGE OF R.D. MEMORIAL COLLEGE OF
NURSING ,BHOPAL NURSING ,BHOPAL
HEALTH ASSESSMENT OF INFANT

2.  Name Of The Infant :- Baby of Mrs. Sunita
 Age( In Month) :- 18 Days .
 Gender :- Female.
 Father's Name :- Mr. Dharmendra Prajapati
 Mother's Name :- Mrs. Sunita Prajapati.
 Educational Status :- Father- 12th
,Mother- 5th
pass
 Occupation :- Shopkeeper
 Mother :- Housewife
 Type Of Family :- Nuclear Family.
 Income Of The Family :- 9000 Per Month.
 Nature Of The House :- Kaccha.
 Address :- Barkhedi Kalan Bhopal.
 BIRTH HISTORY
 Birth History Of The Child :- Normal Vaginal Delivery ( NVD).
 Date Of Birth :- 8/ 11 /2016 .
 Mode Of Delivery :-Normal Vaginal Delivery.
 Place Of Delivery :- At hospital.
 Birth weight :- 2.7 kg .
 Apgar score at birth :- Normal

3. Weeks/Months Growth And Development Achieved Not
Achieved
Remark
0-4wks -Response to sound ,stares at faces
follows objects briefly with eyes.
-Vocalizes: oohs and aahs.
-Can See black and white patterns
Smiles laugh.
-Hold head at 45 degree angle.
Yes
Yes
Yes
2 month
-Vocalizes : gurgle and coos
-Follows objects across field of -vision
noticed his hands
-Holds head up for short period
-Smiles ,laughs
-Hold head at 45 degree angle
-Makes smooth movements
3 month
-Recognizes your face and scent
-Hold head steady
-Visually tracks moving objects
-Squeals, gurgles, coos
-Recognizes your voice
-Does mini push ups
-Rolls over from tummy to bed
-Turns towards loud sounds
-Can bring hand together bats at toys

4. PHYSICAL EXAMINATION:-
GENERAL APPEARANCE : clean and healthy baby.
HEAD TO TOE EXAMINATION :-
S.No. Part Of Examination Remarks
1. SCALP
a) Colour Of The Hair Brownish.
b) Anterior FontoNellae. Open.
c) Posterior FontoNellaE open.
D) Any wounds Or Birth Markings. No any.
2. FACE AND NECK
Eyes (Colour, Bitot Spots ,fOreiGn Body). Black
Ear Normal Placed
Nose (Running, Blocked , Deviation). Waterly
Mouth ( Teeth Eruption, odouR, Any Abnormality). Moisture
Tongue Pink
Throat ( Odour , Any Signs And Symptoms Of Tonsillitis No Patches
White Patches On The Check No
Distensions Of The Neck veins No
3. CHEST
Shape Of The Chest ( Barrel pigeon,Cylindrical.) Cylindrical
Auscultation ( Breath ,Sounds, Heart Sounds ) No breath
Percussion(fluid,air collection) no fluid
Sign And Symptoms Of Pneumonia. No any
4. ABDOMEN:
Any Distension. No
Auscultation( Bowel Sounds ). No

5. Percussion Smooth.
Palption (Liver , Other Organs Of The abdomen). Normal.
Bowel And Bladder Movements. Normal.
5. EXTREMITIES :
Any Abnormalities Seen ? No any
Manipulation ( Movements Of The Joints). Proper
6. SKIN INFECTION:
Color Of The Skin Pinkish
Skin Rashes Not Present
Any Sign And Symptoms Of Dermatitis No any
Anthropometric Measurements /Nutritional Assessment
 Height :-Actual 40cm (Expected 45 cm)
 Weight :-Actual 2.7 kg. (Expected 3.5 kg)
 Head circumference :- Actual 33 cm. (Expected 35 cm.)
 Chest circumference :-Actual 31 cm. (Expected 34 cm.)
 Mid arm circumference :-Actual 10 cm . (Expected 11-13 cm.)
DiETARY HISTORY:-
DIET FROM TO
Breast milk 28/10/16 27/4/17
Weaning ---- ----
Common family diet ---- -----
Actual :- 15 DAYS ( Expected :- on demond )

6. Sings of malnutrition (if any) :- Not present in baby and mother .
IMMUNIZATION :-
Vaccine 1st
DOSE 2nd
DOSE 3rd
DOSE BOOSTER DOSE
“O” polio √ --- -- ---
BCG √ --- -- ---
DPT ,OPV √ ---- --- ---
Measles --- --- --- ---
Student sign................ Evaluator sign...........

7. Sings of malnutrition (if any) :- Not present in baby and mother .
IMMUNIZATION :-
Vaccine 1st
DOSE 2nd
DOSE 3rd
DOSE BOOSTER DOSE
“O” polio √ --- -- ---
BCG √ --- -- ---
DPT ,OPV √ ---- --- ---
Measles --- --- --- ---
Student sign................ Evaluator sign...........