assesment

Alexis Spikes, LVN, completed a physical assessment on six-year-old Aubrey Adams. Aubrey's vital signs and measurements were recorded, and her medical history was reviewed. Aubrey is up to date on vaccinations and has no known allergies. The family history includes heart disease, hypertension, and mental health issues. Aubrey has dyslexia and receives special education for it. There have been instances of domestic violence in the home, but it has decreased. Aubrey's overall health and development are normal, and she is doing well in school. There are teaching opportunities regarding second-hand smoke, violence exposure, and thumb sucking. The mother prefers oral teaching. The physical assessment showed no abnormalities. Aubrey is in the industry versus inferior stage of development and participates in extracurricular activities. This is Alexis Spikes, LVN. I currently completed a physical assessment on patient Aubrey Adams. At the time of assessment, her guardian Celeste Foster, who is her mother, was present. And she also gave me verbal permission to complete the assessment for a school project. The date is 2-9-24. Current time is 1-22 p.m. This patient is six years old. Her date of birth is 4-20-2017. She's a female. Her current bottle size, her temp was 97.6. Pulse is 83. Respiration is 22. Blood pressure 116 over 74. And her O2 saturation was 99% on room air. She is currently 98 pounds with 2 ounces. She is 46 inches. Her head circumference is 22.3. She currently is seeing provider Carrie Hunt for all pediatric needs. She has not been admitted to any healthcare facilities in the past 12 months. Her last exam with her primary care, her pediatrician, was on 1-16-24, which no abnormalities were found per the mother. She takes a daily multivitamin. This medication was verified, and also the location was verified as the cabinet in the kitchen, which is out of reach of the child and the other children in the home. She does not have any allergies. She had no abnormalities at birth. She was born at 71 weeks, a vaginal delivery with no complications. Her birth weight is 6 pounds 5 ounces. She was born at Jasper Memorial Hospital in Jasper, Texas at 425 AM. The mother did have anemia while pregnant with the child. However, she did not have to have any transfusions at birth. The child has never been hospitalized. Per the mother, she has met all developmental milestones up until her age of 6 years old with no delayed development in any area. The mother was able to provide me a shot record, and she has verified the patient is up to date on all vaccinations. She has never been exposed to any known illnesses per the mother that she knows of, and she's never been diagnosed with any communicable disease. Her family health history includes heart disease, hypertension, and mental health. The heart disease is from her maternal grandmother. The hypertension is from her maternal grandmother. The mental health is from both her mother and her father. The mother is 25. She suffers from depression and anxiety, and her father is bipolar. He's also 25. She has a sister that's 4 years old. She also falls into the category of heart disease. She was diagnosed with congenital heart defect at birth. She has a sister that's 2 years old, and she has severe eczema. And then she also has a brother that's 8 months old, and there's no health issues with him. Social information. She has a good appetite. Her favorite foods per the child are pizza, chips, cookies, and tomatoes. She dislikes onions. She does suck her thumb and was sucking her thumb at the time of the assessment. The mother noted that she had sucked her thumb since she was a baby. Her dad is present in the home, and he also is a smoker. The mother states that he does sometimes smoke in the home as well. The child does have fears. The fears were noted as she is scared of clowns and she's scared of the dark. The mother states that she does have a difficulty sleeping at night. She said that she's taken her to a primary care physician before about it, and she said that she just may have some insomnia. She was just advised to take the games away from her and limit television time and drinks and food closer to bedtime. She is in kindergarten at Fu Primary in Jasper, Texas. She was diagnosed with dyslexia, so she is in classes for that, in special classes for that, learning disability. The only thing that the mother stated that may be going on in the home is that her and the father have had some difficulties with communication and there's been some domestic violence in the home previously in which the child had been exposed to. However, the mother stated that it has decreased, but it's still present. The mother is currently working as a nurse with a hospice company. The father is also employed. However, the mother states that she is the only one that pays the bills, so to put the financial strain on the mother. The dependents in the home that may have any issues, the four-year-old sister, she does have constant doctor's appointments for her heart defect, so that kind of draws the attention away from the child. They live on the second floor of an apartment. She shares a room with her four-year-old sister. The kids have their own separate bathroom, which is located across the hallway from their bedrooms. No current religious practices and no cultural practices that need to be honored. As far as support, they do have family friends, friends of the mother and the father that come in and help, and also the grandmother is also a big support. The maternal grandmother is also a big support for the family, for the child. Patient conflict or family conflict, like I stated before, the only conflict that the mother was able to disclose was between her and the father, that they have been violent before in physical and the child had been exposed to those things. Patient has a regular diet, no issues with dietary needs. She's not had any weight loss in the past six months. She does have a feeding tube. She currently falls on the chart of adequate growth for her age. She has very good skin color, was adequate, no cyanosis noted. Activity is very good. She's very active during the interview, kind of pacing back and forth between the kitchen and the living room. She's able to talk to me very well. She is ANO times three. She's six years old and she's continent. The mother states that she has been continent since she was two years old. She did have episodes of bedwetting at three. However, she says she hasn't had any issues since then. Per the mother, school-wise, educational-wise, the child is excelling in school. She is very eager to learn and ready to learn at school. Like I said, she does have dyslexia, so that is also a limitation for her educational needs. The teaching that could be present for this patient and the family is second-hand smoke effects. The family could be taught for exposure to violence, and also the child as well as the family needs to be educated on thumb sucking. Who is available for the teaching? Per the mother, the father would be interested or would be available to teach as far as the mother. They prefer oral teaching instead of any kind of paper handouts. She said they don't really like to read. They get a ton of papers and she said they probably would just throw them away. So she would prefer the teaching orally. As far as the assessment portion goes, As far as the assessment portion goes, she is anosome 3. Her speech is within normal limits. Her pupils are reactive to light. Her hearing is within normal limits. She does have preocular pits on both ears that have been present at birth. The mother states that she has pointed those out to the pediatrician. The pediatrician said just make sure that they stay clean. If they seem to be infected, just bring the child in and she would take a look at them. But she said that she's had no issues with those. Her respiratory is within normal limits. Lung sounds were clear in all four quadrants. She doesn't have a cough and she hasn't had any respiratory issues since birth. Besides just your normal cough, cold, those type of symptoms, but nothing severe. The patient has no cardiac issues. Her heart was in normal rhythm. No chest pains, no edema, no cyanosis noted. Her capillary refill was adequate, less than 30 seconds. She doesn't have any GI issues. According to the mother, she hasn't ever had any issues with that. She's been continent of bowel since she was 3. I didn't hear active bowel sounds in all four quadrants. No tenderness, palpation. And the patient did not display any distention of her abdomen. Musculoskeletal was within normal limits. She walks, does not have any shuffling gait. She does not have any weakness. No swelling noted. And the mother states that she's been walking since she was about 1. So she hasn't had any issues in that area. Endocrine was within normal limits. She's 6 years old, so she's started menstruation. And the mother does not do kind of any breast exams. She's never been diagnosed with any kind of endocrine disease. Urinary, the mother states that she kind of goes about 5 to 6 times a day. No burning when urination. Per the child, there's no burning when she urinates. No difficulty urinating. She has no discharge, no edema. The last time she voided, the mother states, about an hour. And it was yellow and clear in color. No vaginal discharge. She's never had a pap smear. And she hasn't had any incontinence since she was 3. The mother didn't have any concerns. Okay. Okay. Her skin was intact. No scars noted. I asked the mother about any maybe childhood bump, bruises, anything like that. The mother states that she doesn't have anything. The mother was not comfortable with a full examination of the child as far as any type of removing of the bottoms of the clothes. So I respect the client's wishes and the mother's wishes. And I just got those answers from her. So she's noted that there was nothing on her that needed to be looked at. She doesn't have any eczema. The child's sister, the 2-year-old sister, does suffer from severe eczema. And that's the only family history of any kind of skin problems. The client denies any kind of pain at this time. During the assessment, the child seemed very happy. She seemed well-groomed and clean, no issues in her general appearance. So what I was able to gather from this, that the child, Ms. Adams, she currently is a school-age child. As far as Erickson's stage of development, I feel like this child is in industry versus inferior. I say this because I believe that, well, according to the mother, the child does do extracurricular activities. She plays softball and soccer. The mother says that she's very happy to do those activities during practice and games. She likes to be very competitive with her friends. It makes her happy. However, when she feels defeated when they lose a game or if one of her friends is better than her, then she also feels sad and defeated. So in that area, you know, she may have some ups because she is, you know, getting to that age to where she is feeling like she's doing better. She's doing really good. She's finding herself. She's competitive, but then also when it seems that those things are less than what she expected or wanted, then she feels inferior to her peers, her surrounding, her friends, because she feels defeated because they did better or the team lost. Based on the data collected from my assessment, I did identify some risk factors. One was a risk for mental health issues as her mother suffers from depression and anxiety and her father from bipolar. Another was a risk for secondhand smoke inhalation due to her father smoking. Another was a risk for learning difficulties due to dyslexia. Another was a risk for cardiac issues due to maternal family issues with cardiac problems. Risk for violent behavior or fear due to exposure to domestic violence. Risk for inadequate sleep due to insomnia. So with those risk factors, what I kind of gather that could be taught to teach the no smoking in the home for the risk for the secondhand smoke. The mother stated that the father is the primary smoker in the home. And she said that he has been educated and told, but she said that he continues to do so. So I think that just continuing education would be in that area. I would seek family counseling or give the family some teaching about what domestic violence exposure kind of does to a child, as well as what the risk factors of just being coming from a parent that has depression, anxiety, or any type of mental health issues. That child could be very much so dealing with things that the parents are not aware of. And maybe talking to an outside source that will be able to identify and the child will be able to cope with any type of issues she may be having, even as far as seeing her parents argue or fight violently in front of her. The child will need additional help with schoolwork. Maybe she could receive a tutor. She does. The mother did say that she does go to a different class sometimes during the school period, the school day, to just get help, extra help with work and tests. So just educating the family on kind of the risk factors and the side effects of dyslexia. So they don't get agitated with her when she doesn't do things appropriately as far as reading, writing. They just need patience with her. And then also routine checkups. Just kind of educate and relate to the mother how important it is for the child to receive those checkups due to all the risk factors that she is exposed to. The secondhand smoke, the mental health issues, the history, the secondhand smoke inhalation, the dyslexia, the insomnia. Just making sure that that child is checked by a physician or pediatrician on a routine basis is necessary. My two nursing diagnoses that would apply to this patient would be fatigue related to insomnia, as evidenced by a mother stating the child does not sleep well at night and falling asleep in class. Another is a risk factor for depression related to genetic factors, as evidenced by a mother saying she has been diagnosed with depression since 16. The mother did state that the child has come home multiple times with notes from the teacher stating that she is falling asleep in class and that she is actually slipping behind in her grades because of that. And the mother stated that she has taken the steps and precautions that was provided by the pediatrician as far as limiting snacks or drinks at nighttime to reduce having to go to the bathroom. And she's also cut TV time when close to the nighttime. However, she states that the child is still suffering from this insomnia. Okay, at the conclusion of the assessment, the patient nor the mother had any complaints, concerns, and both were very happy and very cooperative.