BT is a 5 y.o. male who came to the clinic with his mother for a wellness exam. The patient's last
physical was 2 years ago, and he is behind on
... [Show More] vaccinations. He currently has no known allergies
and not taking any medications. BT is overall healthy, active, social, and eats a balanced diet. He
had regular bowel movements, takes his multivitamins, and has a great family dynamic. The
patient had no history of family illnesses, no hospitalizations, and problems with his sleep.
Plan:
Therapeutic - Pharmacological:
- Administration of the following vaccinations:
- MMR 0.5 mL Subcut right deltoid
- IPV 0.5 mL Subcut left deltoid
- Influenza 0.5 mL IM right anterolateral thigh
- DTap 0.5 mL IM left anterolateral thigh
- Varicella 0.5 mL Subcut left deltoid
Non-pharmacological:
- Children’s multivitamin once daily
- 6-8 fluid oz. of water
- 10-13 hours of sleep each night
- If sent to ED or directly admitted, ensure the child is receiving supportive care
through eating his favorite foods, resting, and reassuring the child is safe with the
parent. Prevent separation with child, allow child to feel at home by providing
similar at-home routines, monitor the child for depression or change in behavior.
Social Determents of Health:
- Ensure the child has appropriate air-conditioning at home and school – heat can
cause inability to focus or sleep due to discomfort.
- Ensure the child has safe transportation to school and back.
- Ensure the child is in a safe at home free of drugs and violence.
- Ensure the child has access to nutritional foods and clean filtered water.
- Ensure the child has smoke-free environment at home and in the car.
- Ensure the child does not have access to alcohol and drugs.
This study source was downloaded by 100000852290574 from CourseHero.com on 12-07-2022 12:27:21 GMT -06:00
https://www.coursehero.com/file/157741177/IHUMAN-Buddy-Plandocx/
Health Promotion:
- Ensure the child meets expected developmental milestones physically, socially,
and cognitively by recognizing their conversations, following directions,
performing simple chores, playing with other children, identifying alphabets and
numbers, and being able to hop on one foot.
- Monitor the child for abnormal physical, social, or health findings.
- Ensure the child receives all scheduled vaccinations when due.
- Ensure the child maintains dental health by brushing twice a day, flossing, and
scheduling dental visits.
Patient Education:
- After vaccination, child may feel soreness, swelling, fussy, and experience GI
distress.
- Ensure the child wears swim ear plugs to prevent reoccurrence of ear infections.
- Ensure the child is using the restroom throughout the day before and after stops.
- Ensure the child is sleeping 10-13 hours/day
- Ensure the child is active and has play time every day.
- Limit the use of screen time to 1 hour/day and monitor what the child is watching.
- Help prevent cavities in your child by ensuring the child is brushing his teeth
twice a day.
- Ensure all guns and ammunition are locked away and inaccessible to child.
- Ensure your child is wearing a helmet and keep away from the street when riding
scooter/bicycle.
Consults:
- Referral to Dentist for dental check-up and cleaning at least twice a year.
Follow-up:
- Follow up in one year for next schedule of vaccination including Influenza.
References
Bickley, L. S., Szilagyi, P. G., & Bates, B. (2017). Bates' guide to physical examination and
history taking (12th ed.). Philadelphia: Lippincott Williams & Wilkins. [Show Less]