INTRODUCTION: As a post of Community Health Field Posting, I was posted in Primary Health

centre, Bhatagaon, Raipur, during this posting one of our objective was to gain in-sight to develop
and implement Individual Health and Nursing Care Plan

Growth and development distinguish child from an adult and it is essential feature of life of child. For
early identification of child’s malnutrition and inadequate health or any illness measuring growth and
development is essential part of child care. During clinical experience I select one infant to give
comprehensive care.

PERSONAL IDENTIFIICATION

Name of infant: baby Shiva

Father’s name: Mr. Milap patel

Mother’s name: Mrs. Tara patel

Age: 02 month

Sex: Male

Address: Lohandiguda, jagdalpur c.g.

FAMILY CHARACTERSTICS:

Type of family: Nuclear

Size of family: 4

Religion: Hindu

S. Name Age Sex Education Occupation Immunization Marital Remark

N0 status
.
1. Munnibai 49 F Illiterate Housewif Complete Widow Good
yr e
2. Milap 23 M 8th Carpenter Complete M Good
yr
3. Tara 20 F 1st Complete M Good
yr Housewif
e
4. Shiva 10 M - - inprocess UM Good
m
 FAMILY GENOGRAM

40 y

Mrs. Munni

23 y 20 y

Mr.Milap 02 mon. Mrs.Tara

Mr. Shiva

INDEX

MALE

FEMALE

DEATH

LIVING TOGTHER

MARRIGER

PERSONAL HABITS:

No habits of addiction, alcoholism in the family.

Sometimes used tobacco but not in routine.
Hygiene of children and house was maintained
Believes in prayer and god

NUTRITIONAL STATUS:

Feeding habit of infant found good

Staple food: wheat, rice

Diet: vegetarian

ONE DAY MENU

Breakfast : chapatti or bread and tea

Lunch : chapatti/ Rice, dal, vegetable and curd

Evening : Tea with Snacks

Dinner : Chapattis, dal, vegetable, salad

Fruit : Taking daily, adequate

PHYSICAL ASSESSMENT

Body Fluid : Lean builds

Scalp & Hair : clean

Face : found clean

Eyes : found clean and bright

Nose : clean and dry nostril no discharge

Oral Cavity : Clean

Gums : Firm and Pink

Teeth : Nil

Tongue : Clean, Pink and Moist

Ear : Clean and dry

Skin : Clean with good texture

Glands : Not palpable

Chest : No any abnormality

ENVIRONMENTAL FACTORS

HOUSING

Type of House : Pucca

No. of rooms : 2

Kitchen : separate

Ventilation : Inadequate

Toilet and Bathroom : attached

Light : using electricity

Living space per head : Inadequate

Source of water supply : Water supply from tap.

Drainage system : Closed drainage system

Method of waste disposal : MCD dustbin.

SOCIO-ECONOMIC STATUS

INCOME EXPENDITURE

N0. Of earning members : There is only one earning member Mr. Milap

Total Monthly income : Rs. 8,000

Per capita income : Rs. 2,000

Family is not satisfied with income because there daily needs are very costly. And only one is earning
member in their family.

RELIGION

They are Hindu and celebrate Dipawali as major featival and also celebrate other mini festival like
Holi, rakshabandhan, etc. they believe in fast and other Hindu festival.

KNOWLEDGE ABOUT HEALTH MATTER

Family members are having outlook towards the health and disease. They aware about the health
services available in Bhatagaon

Abdomen : Re-proportionate to body for age.

Nails : Long.

Extremities : Proportionate to body size.

ANTHROPOMETRIC MEASUREMENT

S.N0 CRITERIA PRESENT EXPECTED REMARKS

.
1. Weight of the infant 7 kg. 7.5kg Normal
2. Length of infant 60cm 60-65cm Normal
3. Head circumference 43cm 43cm Normal
4. Chest circumference 43 cm 43 cm Normal

DEVELOPMENT ASSESSMENT

ITEMS EXPECTED SEEN IN INFANT REMARK

Gross Motor Symmetric posture of
head and body. Very slight
head long when pulled
from supine to sitting
position
Fine Motor Hands open/closed
loosely, hold object put in
hand with active group
Psychologica Sense of trust recognizes
l and smiles in response to
care givers.
Interested in surrounding
Sleep Sleep at least 12-14 hours.
Expensive Cries less show pleasure
Infant was slightly headed Normal
lag when pulled from the
supine to sitting position
Infant was putting his hand Normal
and object to mouth
Infant recognizes his Normal
mother and stop crying
when he hold by mother
Sleep for 12-13 hours Normal
Infant was gives response Normal
 Language in making sound and to sound.
vocalization.

IMMUNIZATION STATUS

Infant has got BCG, OPV, Measles and advised to get, DT,TT

DIETARY PATTERN

Infant takes Mothers breast milk with weaning foods like

 Liquid semisolid foods like Biscuit soaked in milk, mashed banana, mashed and boiled potato, etc.
 Khichri, egg yolk and mixture of rice and dal.

SOAPIER OF BABY SHIVA 14.04.14

IST VISIT
OBJECTIVES:
 To introduce self and explain the purpose of family visit.
 To establish interpersonal relationship with the family.
OBSERVATION
After maintaining IPR, information collected regarding family and infant which are selected for care:
Temperature : 370 C
Pulse : 110/ minute
Volume : good

ADVICE
 Advised mother to keep infant clean and home also.
 Advised mother for breast feeding.
 Proper position of breast feeding.
 Advised burping after breast feeding.

SOPIER OF BABY SHIVA 15.04.14

2ND VISIT

OBJECTIVES:

 To collect information about family and about infant in detail.

 To assess the growth and development in detail.
 To provide need based education.

OBSERVATION:

Temperature: 370 C

Pulse: 112/min.

Volume: Good

Complete growth and development assessment of infant is done.

Height (length): 60 cm

Head (length): 43cm

 Cheats circumference: 43cm

Weight: 7 kg

ADVICE

 Bring the infant for remained immunization.

 Advise for cleanliness of breast before and after feeding.
 Instruct do not apply kajal to eye.

SOAPIER OF BABY SHIVA 16.04.14

OBJECTIVES

 To explain about prevention of minor ailments in infant.

 To provide need based health education.

OBSERVATION:

Infant has common cold:

Temperature: 37.20 C

Pulse: 114/min

Volume: good

ADVICE
 Explain about prevention of minor ailment among infant as fever, cough, cold, diarrhoea.
 Instruct to wear worm clothes to infant
 Advised mother if fever and cold increase immediately bring the child to the hospital.

SOAPIER OF SHIVA 17.04.14

4TH VISIT
OBJECTIVES
 To educate mother about proper child care
 To provide follow up
 To provide health education.
OBSERVATION
Temperature: 370 C
Pulse: 110/min
Volume: good
 Infant’s condition was improved coughing, sneezing and watering from nose decreased.
 Infant seen some active.
ADVICE
 Advised to maintain personal hygiene of infant E.g. Bathing, Wearing clean cloths etc.
 Advise to check repeatedly nappy, to prevent wetness and prevent infant
 Advised for remaining immunization.