Zachary LaFontaine Objective data Collection

Zachary LaFontaine Objective data Collection

This detailed assessment includes measurements, growth curves, and inspections across multiple domains, providing a comprehensive overview of Zachary’s overall well-being.

Body:
Zachary’s growth metrics, such as head circumference, weight, and length percentiles, were meticulously recorded, with a detailed analysis of growth curve trends. The examination extended to facial features, skin condition, and mucous membrane assessments, offering valuable insights into his general health status.

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In-depth examinations of the ears, eyes, extremities, and musculoskeletal system were conducted to evaluate sensory and motor functions. Reflexes, including the Moro, rooting, sucking, and tonic reflexes, were assessed, providing valuable information on Zachary’s neurological development.

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Furthermore, a comprehensive evaluation of cardiovascular and respiratory systems, including pulse, heart sounds, and lung auscultation, contributed to a holistic understanding of Zachary’s vital functions. This extensive documentation of objective data establishes a solid foundation for subsequent analysis and the development of a tailored care plan to address Zachary’s specific health needs.

Conclusion:
In conclusion, the comprehensive objective assessment of Zachary LaFontaine’s health status serves as a valuable resource for healthcare professionals. The detailed examination across multiple domains provides a holistic understanding of his physical development, offering crucial insights for the formulation of an informed and personalized care plan. This essay format highlights the significance of objective data in enhancing our understanding of an individual’s health and guiding appropriate interventions.

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Zachary LaFontaine Objective data Collection

 Growth Chart: Head Circumference
1 of 1 point
Head Circumference Percentile (1/2 point)
  •  Below 5th percentile
  •  Between 5th and 95th percentile
  •  Above 95th percentile
Head Circumference Growth Curve (1/2 point)
  •  Growth curve maintained
  •  Growth curve decline
 Growth Chart: Weight and Length
0.83 of 1 point
Length Percentile (1/6 point)
  •  Below 5th percentile
  •  Between 5th and 95th percentile
  •  Above 95th percentile
Length Growth Curve (1/6 point)
  •  Growth curve maintained
  •  Growth curve decline
Weight Percentile (1/6 point)
  •  Below 5th percentile
  •  Between 5th and 95th percentile
  •  Above 95th percentile
Weight Growth Curve (No point)
  •  Growth curve maintained
  •  Growth curve decline
Weight For Length Percentile (1/6 point)
  •  Below 5th percentile
  •  Between 5th and 95th percentile
  •  Above 95th percentile
Weight For Length Growth Curve (1/6 point)
  •  Growth curve maintained
  •  Growth curve decline
 Inspected Nose
1 of 1 point
Nares Inspection (1/3 point)
  •  Pale
  •  Pink
  •  Erythematous
Mucus (1/3 point)
  •  Thin white mucus present
  •  Thick yellow mucus present
Nares (1/3 point)
  •  Patent
  •  Obstructed, not patent single sided
 Inspected Ears
1 of 1 point
Inspection (1/2 point)
  •  Ears set appropriately
  •  Ears low set, posteriorly rotated
Pinna (1/2 point)
  •  Pinna flexible
  •  Pinna stiff
 Inspected Mouth
1 of 1 point
Frenulum (1/4 point)
  •  Frenulum intact
  •  Frenulum thick
Palate (1/4 point)
  •  Palate intact
  •  Palate open
Tongue (1/4 point)
  •  Tongue smooth
  •  Tongue rough
Uvula (1/4 point)
  •  Uvula midline
  •  Uvula absent
 Inspected Skin
1 of 1 point
Color (1/8 point)
  •  Cyanosis
  •  Jaundice
  •  Pallor
  •  Congruent with genetic background
Texture (1/8 point)
  •  Smooth
  •  Rough
Temperature (1/8 point)
  •  Warm
  •  Cool
Skin Hydration (1/8 point)
  •  Elastic
  •  Tenting
  •  Sluggish turgor
Lesions (1/8 point)
  •  No visible lesions
  •  Laceration/wounds
  •  Erythema
  •  Ecchymosis
  •  Birthmark
  •  Discolorations
Mucous Membrane: Hydration (1/8 point)
  •  Moist
  •  Dry
Mucous Membrane: Appearance (1/8 point)
  •  Intact
  •  Cracked
  •  Blistered
Mucous Membrane: Color (1/8 point)
  •  Pink
  •  Pale
  •  Erythematous
 Inspected Diaper Area
1 of 1 point
Inspect Skin Diaper Area (1/1 point)
  •  No lesions present
  •  Macerated
  •  Edema
  •  Erythema
 Inspected Genitalia
1 of 1 point
Appearance (1/5 point)
  •  Urethral meatus midline
  •  Hypospadias
  •  Ambiguous genitalia
Palpation (1/5 point)
  •  Testes present bilaterally
  •  Testes not palpable
Rugae (1/5 point)
  •  Smooth
  •  Rough
Masses (1/5 point)
  •  No masses
  •  Mass palpable
  •  Swelling
Circumcision (1/5 point)
  •  Circumcised
  •  Uncircumcised
 Assessed Musculoskeletal: Barlow and Ortolani
1 of 1 point
Barlow (1/2 point)
  •  Positive
  •  Negative
Ortolani (1/2 point)
  •  Positive
  •  Negative
 Assessed Eyes: Pupils
1 of 1 point
Shape (1/3 point)
  •  Round
  •  Abnormal shape
Light Reaction (1/3 point)
  •  No reaction to light
  •  Reacts to light symmetrically
  •  Reacts to light asymmetrically
Opacity (1/3 point)
  •  Clear
  •  Cloudy
 Assessed Eyes: Red Reflex
1 of 1 point
Red Reflex (1/3 point)
  •  Absent
  •  Present
Color (1/3 point)
  •  Equal color bilaterally
  •  Unequal color bilaterally
Opacity (1/3 point)
  •  Opacity absent
  •  Opacity present
 Assessed Eyes: Tracking
1 of 1 point
Vision Screening (1/1 point)
  •  Follows object in both directions
  •  Does not follow object in both directions
 Assessed Extremities
1 of 1 point
Movement (1/2 point)
  •  Moves all extremities
  •  Does not move all extremities
Symmetry (1/2 point)
  •  Movement symmetrical
  •  Movement asymmetrical
 Assessed Grasp
1 of 1 point
Grasp (1/3 point)
  •  Intact
  •  Not Evident
Tone (1/3 point)
  •  Strong
  •  Weak
Symmetry (1/3 point)
  •  Symmetrical
  •  Asymmetrical
  •  Absent
 Assessed Moro Reflex
1 of 1 point
Moro Reflex (1/2 point)
  •  Normal Response
  •  Weak response
  •  Absent response
Hearing (1/2 point)
  •  Hearing intact
  •  Hearing absent
 Assessed Tonic Reflex
1 of 1 point
Neck Range Of Motion (1/2 point)
  •  Symmetrical
  •  Asymmetrical
  •  Absent
Tonic Reflex (1/2 point)
  •  Present
  •  Absent
 Assessed Pulse
1 of 1 point
Pulse (1/2 point)
  •  Regular
  •  Irregular
Amplitude (1/2 point)
  •  Equal bilaterally
  •  0
  •  +1
  •  +2
  •  +3
 Assessed Rooting Reflex
1 of 1 point
Rooting Reflex (1/1 point)
  •  Normal response
  •  Weak response
  •  Absent response
 Assess Sucking Reflex
1 of 1 point
Sucking Reflex (1/2 point)
  •  Normal response
  •  Weak response
  •  Absent response
Tongue Range Of Motion (1/2 point)
  •  Normal response
  •  Absent response
 Assessed Neurological: Stepping/Walking Reflex
1 of 1 point
Stepping Relfex (1/1 point)
  •  Present
  •  Absent
 Palpated Abdomen
1 of 1 point
Light Palpation (1/2 point)
  •  Soft
  •  Firm
  •  Distended
  •  Mass
  •  Bulges
Tenderness (1/2 point)
  •  Nontender
  •  Tender
 Palpated Fontanelles
1 of 1 point
Anterior (1/2 point)
  •  Sunken
  •  Flat
  •  Bulging
Posterior (1/2 point)
  •  Sunken
  •  Flat
  •  Bulging
 Auscultated Abdomen
0.5 of 1 point
Appearance (No point)
  •  Protuberant
  •  Flat
  •  Scaphoid
Auscultation (1/2 point)
  •  Absent
  •  Hypoactive
  •  Normoactive
  •  Hyperactive
 Auscultated Heart
1 of 1 point
Rate (1/3 point)
  •  Regular Rate
  •  Irregular Rate
Rhythm (1/3 point)
  •  Regular rhythm
  •  Arrhythmia
Heart Sounds (1/3 point)
  •  S1
  •  S2
  •  S3
  •  S4
  •  Murmurs
 Auscultated Lungs
1 of 1 point
Appearance (1/3 point)
  •  Symmetrical chest rise
  •  Asymmetrical chest rise
Breath Sounds (1/3 point)
  •  Clear to auscultation
  •  Wheezing
  •  Stridor
  •  Grunting
  •  Absent
Respiratory Effort (1/3 point)
  •  Smooth, even respirations
  •  Nasal flaring
  •  Retractions

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