❖ INTRODUCTION:-
In SSKM Hospital, when I was posted in the Sick Neonatal Care Unit (SNCU ) , I got a Baby (patient)
and his diagnosis was “Low birth weight".
IDENTIFICATION DATA :-
● Name - B/O Mita Hansda
● Identification No - SSKM/RG2302160551
● Age – 1 month 28 days
● Sex - Male
● Bed No- 10
● Ward No - SNCU
● Date Of Admission - 15/11/2024 at 6 Am
● Diagnosis - Low birth weight
● Doctor's Name - Dr.S.Mukherjee
● Name Of Surgery - Nothing Significant
● Date Of Surgery - Nothing Significant
● Date Of Assessment - 18 /11/2024
● Name Of the Informant - Mita Hansda ( Mother)
❖ CHIEF COMPLAIN :-
● ON ADMISSION - The baby was admitted on 15/11/2024 in this hospital with chief complains of low
birth weight, poor sucking reflex.
• AT PRESENT - At present the baby has poor sucking ability .
✓ Sleep - Cry frequently
✓ Appetite - Orogastric tube feeding, ( 25 ml / 2 hrly ) poor sucking reflex
✓ Bowel/ Bladder elimination - Passed urine change 4 diaper /day , Bowel elimination every
10 - 12 hourly.
❖ HISTORY OF PRESENT ILLNESS :- After 1 days of delivery , the baby has been suffering
poor sucking reflex & admitted in SNCU.
❖ PAST HISTORY :-
● Past Medical History - Nothing Significant
● Past Surgical History - Nothing significant
❖ OBSTETRICAL HISTORY :-
ANTENATAL -
● Iron & Folic Acid : Mother was taken 100 tablets of Iron & Folic acid.
● Tetanus toxoid : 2 doses of Inj.Tetanus toxoid was taken by mother during pregnancy.
● Radiation exposure :Mother was not exposed to any radiation during pregnancy.
● Any other medications : Nothing significant
● Any diseases : Nothing significant
NATAL -
● Baby cry - The baby was born in this SSKM Hospital on 24 / 09 /2024 at 11 Pm by cesarean section
delivery.
● APGAR Score - Mother is unable to say
POST-NATAL -
● Mother Condition - After delivery the mother condition was well & satisfied.
● Baby Condition - After 1 days of delivery , the baby has been suffering poor sucking reflex.
❖ PERSONAL HISTORY:-
● Birth weight - 2000 gms
● Gestational age - 36 weeks
● Food habit - Orogastric tube feeding ( expressed breast milk)
❖ IMMUNIZATION :- The was fully Immunized as per age .
❖ SOCIO ECONOMIC HISTORY:-
● Socio economic condition- Well
● Type of House- own and made of concrete.
● Water supply – Tube well
● Sanitation – well( pacca sanitary latrine present )
● Disposal of waste- Landfill in a open place
❖ FAMILY HISTORY :-
● Family type – Joint family
● Members – 2
● Family History – He has a family history of Hypertension but has no family history of congenital
anomalies or any abnormalities.
● Family Composition :-
Sl,No Name of family Relation Age Sex Education Occupation Health status
. members
1. Mr.Jibon Father 36yrs M Illiterate Driver Hypertension since
Hansda 10yrs & taking
medicines as per
doctors order
2. Mrs.Mita Mother 30yrs F (III)passed Home maker Healthy
Hansda
❖ PHYSICAL EXAMINATION:-
General Appearance
• Body Built : Normal
• Color : Fair
• Activity : Lethargic
• Gait: Normal
• Level of Consciousness: Normal
• Behaviour : Normal
• Cry: High pitched
Anthropometric Measurements
Expected normal Child
Measurement
range Picture
Birth weight 2500 gms- 3500 gms 2000 gms
Length / Height 46 - 56 cm 53 cm
Vital Parameters
Expected normal
Parameter Child Picture Remark
range
Heart rate 140-160 bts/m 156 b/m Normal.
Respiratory rate 40-60 bths/m 44 b/m Normal
Temperature 36.5-37.5 degree 37 degree Normal in range.
celcious celcious
Blood pressure 80/40 mm of hg 60/42 mm of hg Normal.
❖ SKIN -
• Colour : Pink
• Skin Turgor : Normal
• Vernix / Lanugos/Mongolian Spot/ /Erythema : Absent
• Sensation : Touch/Pain/Hot/ Cold- Present
• Temperature : warm
• Palpation : Normal findings
❖ Head -
• Shape of the Head : Normal, no abnormality found.
• Hair : shiny, well distributed.
• Scalp : Normal, no infection, dry.
• Injury: Nothing significant
• Fontanels : Anterior: closed
Posterior : closed
❖ Face -
• Look- Fatigue , irritable
❖ Eye -
• Eyebrow: Normal
• Eyelids: Normal
• Eyeball: Normal
• Pupilary reaction: Present
• Discharge: Nothing significant
❖ Ear -
• Placement : In proper alignment
• Symmetry : Symmetrical
• Ear canal : Clean
• Discharge : Absent
❖ Nose -
• External Nose: No blockage, not deviated
• Nostrils: Normal & clean
❖ Mouth -
• Lips: Pink in colour
• Cleft Lip: Absent
• Cleft Palate: Absent
• Presence of oral thrush: Absent
• Odor of the mouth : Clean
• Teeth: Clean
• Mucus membrane and gums: Intact
• Tongue: Clean & healthy
• Tongue tie: Absent
❖ Neck -
• Lymph nodes: Non palpable
• Thyroid glands: Normal
❖ Chest -
• Thorax (Inspection)
Shape: Symmetrical
Breast nodule: normal, symmetrical
• Thorax (Palpation):
Axillary Lymph Nodes: Normal
• Thorax (Auscultation):
Brearh sounds: Audible
Heart Sounds: Audible
Murmur: Absent
• Thorax (Percussion): No abnormality found
❖ Abdomen -
Inspection:-
Shape- Normal
Auscultation:- Bowel sound present
Palpation:- Abdominal girth is 20 cms
Percussion:- (gas/ fluid/ mass): Normal
❖ Back -
• Spinal Curve: Normal
• Spinabifida: Absent
❖ Hip -
• Normal/ Dislocation: normal
❖ Extremities -
• Upper Extremities
✔ Size/ shape/ symmetry: Symmetrical
✔ Fingers (Digit/ Clubbing/ Color): 10 digit,
✔ Palmar creases: Present
• Lower Extremities
✔ Symmetry: Symmetrical
✔ Joints: ROM present
✔ Fingers (Digits/ Clubbing/ Color): Normal
✔ Solar Creases: Present
✔ Edema: present on both legs
❖ Genitalia & Rectum :-
• Boy –
Inspection :
✓ Male genitalia present , scrotum descended normally
✔ Discharge: Nil
GROWTH AND DEVELOPMENT :-
❖ Gross Motor Development -
Book Picture Child Ptcture
Flexed posture with elevated pelvis but knees
not under abdomen unlike at birth. *Head lag present when pulled from supine to
• Head lag present when pulled from supine to sitting position.
sitting position. * Lifts head momentarily when held upright.
• Lifts head momentarily when held upright.
• Turns head from side to side in prone
position.
• Head lags when held in sitting position.
❖ Fine Motor Development -
Book Picture Child Ptcture
• Hands tightly fisted
• Grasps object with strong palmer grasp but drops Grasps object with strong palmer grasp
immediately but drops immediately
❖ Sensory Development -
Book Picture Child Picture
Hearing development Not able to follows light to
• Startled by sudden sound midline placed in distance of 6-9
• Reacts by becoming quiet when inches
hearing voice
Visual development
• Stares indefinite at surroundings
• Fixates on moving objects in front of eyes
Follows light to midline placed in distance of 6-9 inches
❖ Language Development -
Book Picture Child Picture
Expressive language • Cries when hungry or uncomfortable
Makes small throaty sounds • Not able to makes small throaty sounds
Cries when hungry or uncomfortable • Responds to human voices
Makes sounds of comfort during feeding
Receptive language
• Responds to human voices
Psychosocial Development
Book Picture Child Picture
Trust versus mistrust-developmental milestones All of these are not developed
• Depends completely on caregiver
• Enjoy being held and rocked
• Activity diminishes when a human face is seen
❖ DEVELOPMENTAL NEEDS FOR THE CHILD –
✓ Love & security from parents , family members .
✓ Exclusive breastfeeding , providing appropriate environment .
✓ Advised for assessment the child at neurodevelopmental clinic & early identification of developmental
delays .
✓ Explain about available hospital facilities for the child.
✓ Developed discipline leading to self - control .
✓ Develop dependence proceeding to independence .
✓ Developing self – esteem .
✓ Maintain nutrition , oral health ,providing immunizations.
✓ Adopt injury preventing strategies .
