nursing -soap note

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SOAP Note on Infant’s Wellness

 

Name xxxxx

United State University

Primary Health of Acute Client/families Across the Lifespan-Clinical Practicum

xxxxx

Professors xxxxxx

Date xxxxx

 

 

SOAP Note on Infant’s Wellness

Client’s Initial: AJ, Age: 10 months, Gender: Female, Race: Hispanic, Date of Birth: 5th May 2021.

Subjective Data

CC: “Ten-month well-baby check-up.”

HPI: AJ is a ten-month-old Hispanic female, who presents today with her mother for a ten-month wellness exam. Her mother stated that the baby was doing quite well. The mother reported that she tool prenatal vitamins and iron supplements during pregnancy and also iron due iron deficiency. She argued that she did not drink alcohol, smoke tobacco or use illicit drug during gestation. She reported that the baby eats, nurses and sleeps well. The baby shows interest in pureed food and teething snacks. The mother had normal vaginal delivery without any complications.

Past Medical Records: The mother reported that the baby has had a severe anaphylactic reaction to peanuts. She further states that the child has never been admitted in the hospital for major illness nor has she ever been prescribed any medication. However, she takes over the counter children Tylenol elixir titrated per weight and over the counter vitamin D, 1 drop daily. She has been vaccinated currently for stated age. She is joyful, darling, and attentive.

Pregnancy and Birth History: Mother states that she had vaginal delivery with Epidural and without complications. The mother omits APGAR score, Para 4 gravida 4 and full gestational age at delivery. She admits of taking prenatal vitamins during pregnancy and iron supplements due to iron deficiency. However she denies smoking cigarettes, drinking alcohol or using any illicit drug during gestation.

Developmental History: The child has head control, focuses, fixes, and follows. She has two-sided strong grasps works and seizes toys. She is responsive to babbles, coos and sounds. Currently, she has been alters words like dada and mama. She recognizes laughs, faces, feeds self, smiles, and expresses wants. Currently she has right upper central incisor eruption. She uses 3-5 wet diapers and 1 dirty daily.

Feeding History: She is breastfed three times daily. Solids introduced, pureed foods or soft foods two times daily.

Past Medical Procedures: Anaphylaxis 3 months prior, peanuts- Treated in ED with Epi-Pen Junior.

Medications: OTC- Over the counter children, Tylenol elixir titrated per weight and OTC- Vitamin D 1 Drop Daily.

Allergies: no known drug allergies. She has severe peanut allergy.

Family History: her maternal grandfather is 72 years old with hypertension and high cholesterol. Her maternal grandmother, 71 years old with diabetes mellitus type II. Paternal grandfather, 78 years old with high cholesterol and paternal grandmother, 74 years old with diabetes mellitus type II and COPD. Her mother, 36 years old is very healthy, and father, 38 years old with hypertension. Her 12 years old sister is healthy, 9 years old sister was diagnosed with asthma at the age of 3. Her 7 years old brother was diagnosed with ADHD at the age of 6 and he is currently not on medications.

Social History: She lives with her parents and her three siblings in a two-story home with safety measures. The mother reports no parental use of tobacco products or alcohol usage. No parental use of illicit drugs or use of prescription medications for non-medical reasoning. Her mother is a realtor, she has been working from home since the pandemic. Her father also works from home though occupation not revealed. There are no guns at home and no current visits. They have two Labrador kid-friendly dogs. She sleeps on regular patterns, 8-10 hours daily and 2 naps daily. Mother does not disclose spiritual affiliation.

Immunizations: she has been currently immunized on; Hepatitis B, Rotavirus, Diphtheria, tetanus, and acellular pertussis, Haemophilus influenza type b, Pneumococcal Conjugate, Inactivated poliovirus, Influenza, Measles, Mumps, Rubella, Varicella, Hepatitis A, Meningococcal.

Review of Systems

Constitutional: sitting on the mothers lap, the youngster looks to be healthy, happy, and engaging. Weight that is appropriate for the age specified.

Weight: no recent changes, currently 20lbs.

Head: she has no numbness, no loss of consciousness and she has not experienced headaches

Integumentary: she has no inflammation, lesion, or rash. She has no lumpiness. No birthmarks bleeding or bruising.

Neck: she does not have any stiffness, meningeal symptoms or suppleness. She does not have any bruits.

Ears: no ear infections or drainage.

Nose: There is no nasal congestion or runny nose, and she does not have redness and swelling in his nose, no nosebleeds. She also does not have soreness.

Mouth: She has no growths in the mouth, no bleeding gums, no dried lips, no lesions, no ulcers, no mouth irritation, and no tumor on the tongue. Informed of teething and incoming of a tooth on right upper gum.

Skin, Hair, and Nails: she has had no skin rushes, no changes in skin tone and she has no abnormalities in hair color or nails.

Cardiovascular: no shortness of breath; states crawling and squatting tolerated, no heart sounds, denies cyanosis and she has no excessive sweating.

Gastrointestinal: no nausea, vomiting, abdominal pain, one to two bowel movement. No constipation or diarrhea and she has a healthy appetite.

Genitourinary: She denies urine urgency, she has no dysuria, and she has normal urine frequency, average of 3-5 wet diapers a day.

Musculoskeletal: There is no joint swelling, soreness, or pains, and there are no visible joint abnormalities. No scoliosis, bilateral and equal grasps, no gait difficulties, balances well on hands and knees, sits and strives to stand, and the noticed gluteal fold was confirmed to be normal.

Allergies: Denies allergies to medications, Severe Anaphylactic Peanut allergy.

 

Objective Data

Vital Signs

Temperature: 37.5℃, Height: 27 inches, Weight: 20lbs, BP: 92/74, RR: 26, SpO2: 100%, BMI: 25.63, P: 108, Head Circumference: 44.5cm.

Physical Examination.

Constitutional: The child is a well-nourished and developed Caucasian female who appears happy and content.

Head: Her head shape is Noncephalic. Her hair is thick and evenly scattered across the scalp.

Eyes: no visual problems noted. Her eyes are free of edema, and the cornea is completely clear.

Ears: There are no ear infections or ear leakage. Cone of light perceived tympanic membrane pearly gray transparent none retracted none bulging Ears in line with lateral canthi.

Nose: No nasal congestions or nasal flaring noted.

Mouth: No oral thrush or epistaxis, Right upper central incisor eruption, Red Reflex noted.

Neck: In the trachea, there are no tumors, and it is located in the middle. Neither cervical nor axillary lymph nodes nor supraclavicular lymph nodes may be seen in the neck region. There are no nodules or hyperplasia in the thyroid glands.

Lungs: Breath sounds normal, and there are no wheezes, crackles, or coughs. No dyspnea.

Cardiovascular: She has no palpitations, she has no chest pain, no breathlessness, no congestion, she has no heart sounds, no anemia, orthopnea, and she has no excessive sweating.

Abdomen: No umbilicus infections, hernias, or muscle integrity, round, protuberant abdomen. There was no pain or rebound guarding seen.

Musculoskeletal: There is no joint swelling, soreness, or pains, and there are no visible joint abnormalities. Grasps on both sides, and on an equal footing. There are no gait concerns, and she balances well on her hands and knees, sits, and pushes herself to stand. Her gluteal fold was examined and determined to be normal. There is no sacral dimple. No scoliosis, lordosis, or kyphosis were seen, and Ortolani’s and Barlow’s signs revealed no rotational anomalies.

Skin: She has no skin rashes, no wounds, no lumps, and no lesions. Her nails have no deformities.

Neurologic: There are no neurologic abnormalities, and the patient is awake and attentive, according to the Babinski reflex. DTRs with negative tremor/clonus; positive sensation; moves all extremities symmetrically with proper tone.

Genitourinary: Per mother, no abnormalities

Assessment

Primary Differential Diagnosis

Severe Anaphylactic Peanut Allergy– It’s a potentially fatal whole-body reaction to an allergy. Swelling of the throat, a quick drop in blood pressure, difficulty breathing, pale complexion or blue lips, fainting, and dizziness are the most typical symptoms. Peanut allergy symptoms appear practically quickly after eating or handling it. Rarely, responses might take up to four hours to manifest. Delay responses can be difficult to identify because most newborns feed every 2 to 3 hours. By the age of five, about 20% of babies will have outgrown their peanut allergy (Greenhawt et al., 2020).

Febrile- babies may have a “very slight increase in temperature” whenever they’re growing a new tooth. This might be caused by gum inflammation as teeth cut through delicate gum tissues. Since the patient had incisor eruption, febrile is among the differentials (Hayakawa et al., 2020).

Asthmatic Risk- the patient is at risk of asthmatic attack due to family history of asthma. Her 9 year old sister was diagnosed with asthma at the age of three. The common symptoms of asthma include shortness of breath, difficulties when sleeping wheezing when exhaling, which is most common in children (Pijnenburg & Fleming, 2020).

Diagnostic plan

Skin test- The healthcare professional makes a few tiny needle pricks in the back or arm during this examination. On the needle pricks, he next puts modest quantities of several allergy-causing chemicals. After 15 minutes, the skin response is watched and evaluated. An allergic reaction is indicated by skin regions that become red and itching (Gray, 2020).

Treatment

Medication- There is presently no medication available to prevent the development of a peanut allergy. Children may outgrow it over time in some circumstances. Anaphylaxis is treated with the drug epinephrine (adrenaline). Children who are at risk of anaphylaxis should be given an epinephrine auto-injector and should have two doses with them at all times (Dunlop, 2020).

Home remedies- avoid feeding the child peanuts.

Education- the mother is educated on avoiding feeding the baby food containing peanuts. Education on treatment and OTC medication for possible febrile risk of incisor eruption is also important. Parents should also be educated on asthmatic risk and complications, and education on auto EpiPen injector how to use and how many to have (Dunlop, 2020).

Safe environment– Remove anything dangerous, anything that can course a choking hazard, or broken into little pieces from the reach of children. Secure electrical outlets, utilize stairwell gates, and secure doors and cabinets with locks.

Feeding Safety-When your child is eating, always keep an eye on her. Ascertain that your youngster is seated in a highchair or other secure location. Foods that could cause your infant to choke are not to be served.

Follow Up- Follow-up in 2 months for 12- month Well Child Exam and Vaccines series including: Hepatitis B, Haemophilus influenza type b, Pneumococcal Conjugate, Inactivated poliovirus, Influenza, Measles, Mumps, Rubella, Varicella, Hepatitis A, Meningococcal (Dunlop, 2020).

 

 

References

Greenhawt, M., Shaker, M., Wang, J., Oppenheimer, J. J., Sicherer, S., Keet, C., … & Wallace, D. (2020). Peanut allergy diagnosis: A 2020 practice parameter update, systematic review, and GRADE analysis. Journal of Allergy and Clinical Immunology, 146(6), 1302-1334.

Hayakawa, I., Nomura, O., Uda, K., Funakoshi, Y., Sakakibara, H., & Horikoshi, Y. (2020). Incidence and aetiology of serious viral infections in young febrile infants. Journal of Paediatrics and Child Health, 56(4), 586-589.

Pijnenburg, M. W., & Fleming, L. (2020). Advances in understanding and reducing the burden of severe asthma in children. The Lancet Respiratory Medicine, 8(10), 1032-1044.

Gray, C. L. (2020). Current controversies and future prospects for peanut allergy prevention, diagnosis and therapies. Journal of Asthma and Allergy, 13, 51.

Dunlop, J. H. (2020). Oral immunotherapy for treatment of peanut allergy. Journal of Investigative Medicine, 68(6), 1152-1155.

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