Topic: Plan of Care Infant case study

Plan of Care
Instructions
It is anticipated that the initial discussion response should be in the range of 250-300 words. Response posts must demonstrate topic knowledge and scholarly engagement with peers. This is not the only criteria utilized for evaluation; substantive content is imperative. All questions in the topic must be addressed. Please proofread your response carefully for grammar and spelling. Do not upload any attachments. All responses need to be supported by a minimum of one scholarly resource. Journals and websites must be cited appropriately. Citation and reference must adhere to APA format.
Classroom Participation
Students are expected to initially address the discussion question by Wednesday of each week. Participation in the discussion forums is expected with a minimum total of three (3) substantive postings (this includes your initial posting and posting to two peers) on three (3) different days per week. Substantive means that you add something new to the discussion, you aren’t just agreeing. This is also a time to ask questions or offer information surrounding the topic addressed by your peers. Personal experience is appropriate for a substantive discussion and should be correlated to the literature.
All discussion boards will be evaluated utilizing rubric criterion inclusive of content, analysis, collaboration, writing and APA. If you fail to post an initial discussion you will not receive these points, you may however post to your peers for partial credit following the guidelines above. Due to the nature of this type of assignment and the need for timely responses for initial posts and posting to peers, the Make-Up Coursework Policy (effective July 2017) does not apply to Discussion Board Participation.
Discussion Prompt [Due Wednesday]
Week 2 is focusing on health promotion and problems experienced by newborns, infants, and toddlers.
Initial post instructions:
• Please evaluate the subjective and objective information provided to you in the file below.
• The first part of the discussion board is to identify all pertinent positive and negative information.
• Then create a differential diagnosis list with at least 3 possibly actual diagnosis based on your findings.
• Second part is to create a plan utilizing clinical practice guidelines for the priority diagnosis, as well as expected health promotion and expected developmental milestones.
• Be sure to include APA in-text citations and provide full reference citation at the end of the discussion
Attached File
• NU632 Unit 2 Discussion Case
• NU632 Unit 2 Discussion CaseC.C. 2-month-old well-child visitHPI:Mother presents to clinic withD.J. a 2mo 4d old M, for their 2-month-oldcheckup. Mother reports D.J. taking in 6 oz of baby formula every 3 hours while awake. Wakes up once a night for abottle. Having appropriate number of wet diapers and at least 1 BM per day.D.J. does not attend day-care and still at home with Mother. Mother will be going back to work in 4 weeks.Mother reports D.J. smiling and responding to her presents. However,she is concerned that he keeps his turning his head to the rightside and does not turn his head to the left on his own.Has noticed this when trying to get him to turn his head to her. She also has noticed difficulty with holding his head up.Mothernoticed this after birth, but it has become more obvious as he is growing and moving more on his own. The right side of his head is now flat causing a deformity of his head.PMH:Born at 40weeks5 daysgestation vaginally. There were no complications at birth. There were no complications throughout the pregnancy. The infant’s mother denies tobacco use, drug use, or alcohol use during pregnancy. The infant uses Enfamil formula and is not breastfed. The infant received first Hep B immunization.Allergies:No known drug allergiesMedications:NoneSocial History:The infant lives with his mother. Mom will be back to work in 4 weeks. He does not attend day-care at this timebut will in 4 weeks. The infant is not exposed to tobacco smoke.Family History: Mother deniesany significant medical history. Maternal grandmother has hyperlipidemia and hypertension. Maternal grandfather has hypertension.Minimal history on father due to artificial insemination but no significant history is known. Health Maintenance/Promotion: Review of SystemsGeneral:Mother denies any concerns, unexplained fevers, or growth concerns.She is concerned with not turning head.Skin:The infant’s mother denies any rash, lesions, or concerns with eczema.Head: Mother reports the right side of the infant’s head is flat from always favoring his rightside. ENT: Mother denies any concerns with the infant’s ears, nose, or throat.Neck: The infant’s mother reports that his neck is stiff and only turns towards the right side. Per mom hishead is difficult to turn to the right.CV: The infant’s mother denies any cyanotic spells or a discoloration of the skin (cyanotic).Lungs: The infant’s mother denies any cough, congestion, wheezing, or difficulty breathing.GI: The infant is negativefor feeding or food intolerances. The infant is not having difficult with constipation or diarrhea.GU: Negative for diaper rash.ObjectiveVS: Temperature: 98.9F, HR: 152, Ht: 24 in (85.43%), Wt.: 13lbs, 8.6 oz (88.07%), HC: 40.25 cm (57.01%), BMI: 16.5 (48.51%).General: Well developed, well-nourished and hydrated, no apparent distress.Skin: No evidence of rash or lesions.
• Head: Plagiocephaly noted on the right side of the head.Flattening of right cheek. Eyes: The lids and conjunctiva are normal. Pupils are irises are normal fundoscopic exam reveals red reflex present bilaterally.ENT: Normal nose. Asymmetric ears: right ear folded compared to left. Normal external auditory canals and tympanic membranes. Hearing is grossly normal. Lips/teeth/gums: no oral leukoplakia. Oropharynx: normal mucosa, palate, and posterior pharynx.Neck: Infantfavoringright side.Limited ROM noted. Shortened sternocleidomastoid muscle on right side. No palpable lymphadenopathy. Does not appear in distress w/ palpation. CV: Normal rate and rhythm. Normal S1 and S2 heart sounds heard on auscultation with no S3 or S4. No murmurs. Femoral pulse 2+ bilaterally.Lungs: Normal respiratory rate and pattern with no apparent distress. Bilateral breath sounds clear on auscultation without rales, rhonchi, or wheezes.Abd: Normal bowel sounds. No masses or tenderness or organomegaly observed.GU: Penis: normal circumcised male. Testes descended with no inguinal hernia noted.MSK: Grossly normal tone and muscle strength. Normal range of motion in extremities. Negative for “hip click”.

Responses need to address all components of the question, demonstrate critical thinking and analysis, and include peer reviewed journal evidence to support the student’s position.
Please be sure to validate your opinions and ideas with citations and references in APA format.
Please review the rubric to ensure that your response meets the criteria.
Estimated time to complete: 2 hours

Unit 2 – Required Resources
• Burns, C. E., Dunn, A. M., Brady ,M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L. (2016). Pediatric primary care. (6th Ed.). St. Louis, MO: Elsevier. ISBN: 978-0-323-24338-4
o Chapters: 4, 5, and 6
• Pediatric History and Physical Exam (Links to an external site.) [printable PDF]
• Zero to Three (2018). Early Development and Well Being (Links to an external site.). [Website].
• Health Children (2018). Language delays in toddlers: Information for parents (Links to an external site.). [Website].
• Components of the Pediatric Subjective History [printable PDF]
• Physiological Differences Between Children and Adults [printable PDF]
• Child Physical Exam [printable PDF]
• Overview of Growth and Development Theories [Word doc]

Type of service-academic paper writing
Type of assignment-coursework
Subject-not defined
Pages / words- 275
Number of sources-5
Academic level-master’s
Paper format-APA
Line spacing-double
Language style-US English

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