ASSESSMENT OF TODDLER

Name: Hannah Joy Martinez

Address: 362 Brgy Sampaloc 1, Pala-pala, Dasmarinas, Cavite
Birth date: November 25, 2008
Height: 88.5 cm
Weight:
Heart Rate: 110 bpm
Respiratory Rate: 30 cpm
Temperature:

o PERSONAL- SOCIAL
The child is more interactive with other people although there is a
slight anxiety when meeting strangers. She shows independence as
evidenced by using the spoon by herself when eating, drinking from cup, and
removing her garments by herself. She can also imitate adults like doing
housework. She can do simple tasks like running an errand.

o FINE MOTOR ADAPTIVE

She is able to scribble spontaneously and voluntarily. She attempts to
imitate letters. She can make a tower of up to 4 cubes. She can hold a spoon
well but she still has problem controlling her hand movements. She is able to
open doors and small bottles.

o GROSS MOTOR
She can walk alone and can walk upstairs and seats in chairs. She can run
and jump. She can remove her garments without assistance. She can recover
from stooping

o COGNITIVE
She uses trial and error to discover new characteristics of objects or
events. She is able to experiment to discover new properties of objects or
events. She is capable of space and time perception as well as object
permanence.

o LANGUAGE
The child is able to say 2-3 related words. She is still slurry when making
sentences. She sometimes uses nonverbal cues for the adults to understand her
more. She still can’t write letters, but she knows how to scribble and she
attempts to imitate drawn/written objects.

o NUTRITION
The child is on the weaning process. She can eat rice, bread, meat, fruits,
and vegetables, although her diet is composed mostly of milk. She is also fond of
eating candies and sweet food.

o PLAY
She is used to parallel play. She seldom shares her toys to her playmates
but plays willingly with adults.
o ELIMINATION PATTERNS
 She voids not less than 5 times a day. Her usual color of urine is light
yellow. She still voids in bed. She defecates at least once a day in the morning.
Her fecal consistency is moist but formed, yellow to light brown in color.

o DENTAL HEALTH
She lost her two deciduous teeth (upper central incisors). She has dental
caries on almost all of her teeth. She merely brushes her teeth.

o REST AND SLEEP PATTERNS

She sleeps at an average of 10-12 hours. She sometimes takes a nap
in the afternoon.
 HEAD – TO –TOE ASSESSMENT
General Appearance
- Gait - wide based gait
- Posture - lordotic
- Body Built - small, with absence of baby fats
- Mood - happy and actively participating
- Speech - speaks 2-3 words, slightly slurry
- Heart Rate - 110 bpm
- Respiratory Rate - 30 cpm
Skin
- Color - brown, darker in parts exposed to sunlight
- Texture - smooth
- Moisture - not dry
- Odor - no odor
- Thickness - thick for age
- Turgor - good turgor
- Edema - non-pitting
- Temperature - warm to touch
Nails
- Color - pinkish
- Angle - <160 degrees
- Shape - rounded, clean cut
- Capillary Refill - comes back in <3
Hair
- Distribution - evenly distributed
- Thickness - thick
- Scalp Lesions - no scalp lesions
- Infestations - no presence of infestations
- Dandruff -no presence of dandruff
- Use of Products/ Chemicals - uses shampoo
Skull
- Shape - round and symmetrical
- Fontanels - both fontanels are closed
- Concussions - no concussions
- Lesions/ Lacerations - no lesions/ lacerations
Eyes
- Vision Acuity - 20/20 vision
- Tearing - no reports of tearing
- Use of Glasses/ Corrective Lenses - doesn’t use corrective lenses
- Shape - round
- Light Accommodation - good light accommodation
- Discharges -no discharges
- Lid Margins - aligned
- Eye Lash Distribution - evenly distributed
- Conjunctivas - pinkish
- Sclera - white
- Pupils - reactive to light
- Eye Movements - well coordinated
Ears
- Texture - smooth
- Alignment - aligned to canthus
- Discharges - no discharges
- Hearing Deficits - no reports of hearing deficits
- Lesions - no presence of lesions
- Infections - no ear infections
- Piercings - one on each ear
- Ear Cleaning - twice a week
Nose and Sinuses
- Symmetry - symmetrical, midline
- Discharges - no discharges
- Lesions - no lesions
- Polyps - no polyps
- Nasal Flaring - no nasal flaring
- Obstructions - no obstructions
- Snoring - no reports of snoring
Mouth
- Lips - pinkish, smooth, moist
- Gums - pinkish
- Dentures - no dentures
- Toothaches - had reports of toothaches
- Dental Caries - almost all teeth
- Mouth Sores - no mouth sores
- Dental Habits - merely brushes her teeth
- Lesions - no lesions
- Tonsils - not enlarged
- Uvula - midline, not enlarged
Throat and Neck
- Symmetry - midline
- Change in voice - no change in voice
- Hoarseness - no hoarseness
- Sore Throat - no reports of sore throat
- Pain/Stiffness - no reports of pain/ stiffness
- Dysphagia - no difficulty in swallowing
- Lumps - no lumps
Breast/ Axilla
- Symmetry - symmetrical
- Nipples, Areola, Discharges - no discharges
- Pain - no reported pain
- Tenderness - no reported tenderness
- Lumps - no lumps
- Rashes - no rashes
Chest and Respiratory
- Symmetry - symmetrical
- Breath sounds - no breath sounds
- Breathing patterns - regular
- Chest pain - no reports of chest pain
- Dyspnea - no reports of difficulty in breathing
 - Orthopnea - no orthopnea
Cardiovascular and Peripheral
- Color of Extremities - extremities are warm to touch
- Heart Murmurs - no heart murmurs
- Chest Pain - no reports of chest pain
- Heart Disease - no reports of heart disease
Abdominal/Gastrointestinal
- Shape - prominent abdomen (pouchy belly)
- Texture - smooth
- Pain - no reports of abdominal pain
- Appetite - no reports in change in appetite
- Usual bowel habits - once a day in the morning
- Changes in stool color - no changes in stool color
- Stool Characteristics - moist but formed, yellow to brown in color
- Distention - no distention
- Flatulence - no reports of flatulence
Reproductive
- Lesions - no lesions
- Discharges - white and minimal
Genitourinary
- Urine color - light yellow
- Voiding patterns - not less than 5 times a day
- Dysuria - no difficulty in voiding
- Urine Retention - good urine retention
- Flank Pain - no reports of flank pain
Musculoskeletal
- Joint stiffness - no joint stiffness, joints can be flexed without
difficulty
- Range of Motion - full range of motion
- Deformities, dislocations, and fractures - no deformities/
dislocations/fractures
- Pain - no reports of pain
- Weakness - child is active
Hematological
- Bruising - no bruises
- Bleeding - no bleeding present
- Blood Type -
Lymph Nodes
- Enlargement - not enlarged
- Tenderness - non-tender
 MMDST
PERSONAL-SOCIAL
• Imitates housework –pass – the caregiver reports that the child imitates
housework like sweeping the floor
• Uses Spoon, Spilling Little – pass – the caregiver reports that the child can
use spoon while eating, but still spills some food
• Helps in House, Simple Tasks – pass –the child can do simple errands like
handing over an object
• Drinks from Cup – pass – the child can drink on a cup without handle without
difficulty
• Removes Garment – pass - the caregiver reports that the child can undress
herself
• Plays ball with examiner – pass - the child throws the ball to the examiner

FINE MOTOR ADAPTIVE

• Scribbles Spontaneously – pass – the child scribbles lines when given a pencil
and a paper
• Tower of two cubes – pass- the child can make a tower of two cubes
• Tower of four cubes – pass – the child can make a tower of four cubes after
two trials
• Dumps Cheese Curls from bottle – demonstrated – pass – the child dumps the
cheese curls from the bottle after demonstration
• Dumps Cheese Curls from bottle spontaneously – pass – the child dumps the
cheese curls spontaneously the second time without being told

LANGUAGE
• Three words other than mama/ papa – pass – the caregiver reports that the
child can speak three related words other than mama/papa
• Points to one named body part – pass – the child pointed to her eyes when
the examiner told her to
• Combines two words – pass - the caregiver reports that the child can combine
two related words for others to understand her
• Names one picture –fail – after three attempts, the child was only able to
mimic the sound it does rather than telling what it was
• Follows Directions – pass – the child was able to follow directions when the
examiner told her to hand over the blocks to her

GROSS MOTOR
• Kicks ball forward – pass – the child was able to kick the ball toward the
examiner
• Walks well – pass – the child can walk well without assistance
• Walks backward – pass- the child can walk backward without falling
• Walks up steps – pass – the caregiver reports that the child can climb up
stairs
• Stoops and recovers – pass – the child did not fall when picking up a toy
• Throws ball over hand – pass – the child was able to throw the ball over hand
• Balance on one foot for 1 sec. – fail – the child could not balance on one foot
• Jumps in place – pass –the child was able to jump in place when she was told
to
Subjective Data:
 Caregiver verbalizes that her child sometimes has toothaches
 Caregiver reports the child’s dietary habits (eats more candies and sweet
milk) and oral hygiene (merely brushes her teeth)
Objective Data:
 Tooth enamel discoloration
 Erosion of enamel
 Crown and root carries on almost all teeth
 Premature loss of primary teeth (upper center incisors)
 Incomplete eruption of teeth for age (deciduous teeth are 18, 2 upper center
incisors fell out)
Assessment: Impaired dentition r/t dietary habits, ineffective oral hygiene, and
lack of knowledge regarding dental habits
Planning:
At the end of the shift, the client will be able to:
- verbalize and demonstrate effective dental hygiene skills
At the end of the shift, the caregiver will be able to:
- verbalize understanding of the importance of oral health
- encourage and assist the client in her dental hygiene and set as an example
to her
- follow through on referrals for appropriate dental care
Intervention:
1. Note presence/ absence of teeth and ascertain its significance in terms of
nutritional needs and aesthetics.
Rationale: For formulating plan of care and for finding ways on enhancing
client’s confidence
2. Evaluate current status of dental hygiene and oral health.
Rationale: For formulating plan of care
3. Treat/ manage dental care needs through:
a. Administering saline rinses
Rationale: Gargling normal saline helps prevent upper respiratory
conditions (e.g. colds, sore throats)
b. Providing gentle gum massage with soft toothbrush
Rationale: Promotes oral health
c. Assisting/ encouraging brushing at least twice a day.
Rationale: For optimum oral health
d. Advising minimal intake of sugary foods and more on foods rich in
protein, carbohydrates, vitamins and minerals, especially calcium-rich
food.
Rationale: For optimal nutrition and for oral health promotion
4. Promote wellness through client/caregiver teaching by:
a. Instruct client/ caregiver in home care interventions
Rationale: To treat condition and/or prevent further complications
b. Review resources that are needed for client to perform adequate
dental hygiene care
Rationale: For client’s knowledge and accessibility to the needed
resources
c. Discuss advisability of dental check-ups
Rationale: To minimize oral/ dental damage.
Subjective Data:
 Caregiver verbalizes that her child is able to speak but is still slurry when
composing sentences
Objective Data:
 Able to speak a language
 Forms small words and phrases
 Uses and interprets nonverbal cues appropriately
 Imitates written letters though letters are not well formed
Assessment: Readiness for enhanced communication r/t development in child’s
language and cognition Planning:
At the end of the shift, the caregiver will be able to:
- Verbalize/ indicate understanding of techniques that will assist the client to
learn/ comprehend on communication lessons
At the end of the shift, the client will be able to:
- Express information/ thoughts/ feelings in a satisfactory manner
- Write at least her first name
Intervention:
1. Determine client's ability to write and comprehend
Rationale: To evaluate the client’s grasp of knowledge
2. Improve client’s ability to communicate thoughts, needs, and ideas by:
a. Maintaining a calm, unhurried manner.
Rationale: For client comfort
b. Sitting down and maintaining eye contact.
Rationale: To establish trust with the client
c. Paying attention to the client.
Rationale: To establish trust and rapport with the client, and to make her
feel that she is heard
d. Observe body language, eye movements, and behavioral cues.
Rationale: May reveal unspoken concerns
e. Establish hand and eye signals if necessary.
Rationale: To enhance understanding and to enhance cooperation and
interest
f. Provide writing and other learning materials (e.g. picture boards)
Rationale: To enhance learning and interest in learning
g. Reduce distractions and background noises
Rationale: Distracting environment can interfere with communication,
limiting attention to tasks, and making speech and communication more
difficult. Reducing noise can help both parties hear clearly, thus,
improving understanding.
3. Promote optimum communication by:
a. Discussing with caregiver effective ways to which the client communicate
Rationale: For effective communication on both parties
b. Encourage client and family/ caregiver to use successful techniques for
communication
Rationale: Enhances family relationship and promotes self-esteem for all
members
Subjective Data:
 The caregiver verbalizes that her child needs and is willing to be toilet trained
 The caregiver verbalizes that her child still voids in bed
Objective Data:
 Client has developed micturation patterns and has learned how to control
urgency except when sleeping
Assessment: Readiness for enhanced urinary elimination
Planning:
At the end of the shift, the caregiver will be able to:
- Verbalize understanding of client’s condition that has potential for altering
elimination
- Alter the environment to accommodate client’s needs
- Assist the client in achieving normal and healthy micturation pattern
Intervention:
1. Determine client’s voiding pattern and characteristics.
Rationale: To provide baseline data
2. Regulate liquid intake at prescheduled times. Restrict fluid intake 2-3 hours
before bedtime to reduce voiding at night.
Rationale: To promote predictability of voiding patterns
3. Provide assistance/ devices as indicated (potty bowls/ urinals/”arinolas”)
Rationale: for client comfort
4. Promote optimum wellness through:
a. Encourage continuation of successful toileting program and identify
possible alterations to meet individual needs
Rationale: To promote pro-active problem solving and support
normalization of activities
b. Instruct client/ caregiver in cues (voiding on routine schedules, providing
adequate room lighting, easy access to comfort room) that client needs to
improve micturation patterns
Rationale: To promote client comfort
RABE, BLAZEL EDVE MARIE T.
II-BSN-3