Child health assessment_Mat Child.docx - Child Health Assessment Pouliot1 Child Health Assessment Maternal-Child Clinical 2nd Semester Days Ume

Child health assessment_Mat Child.docx - Child Health...

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Child Health Assessment Pouliot1 Child Health Assessment Maternal-Child Clinical 2 nd Semester Days Ume Kulsumbai M Kapacee RN, MSN January 21 st , 2018 Jordynne Pouliot, Student PN-2 Wichita Area Technical College
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Child Health Assessment Pouliot2 Introduction CP is a twelve-year-old female who lives in Wichita, Kansas. She is in the second semester of the sixth grade at Wilbur Middle school. She has 3 brothers, one has the same father as her and the other two have a different father. JP is her father, he is Hispanic-American, and VP is her mother, she is Caucasian. VP is present through the interview. Review of Systems CP’s mother states that she weighs seventy-two pounds and is sixty-one inches tall. This places her in the tenth percentile for weight and the seventy-fifth percentile for her height (Leifer, P. 358). CP’s body mass index is 13.6 which places her in the tenth percentile and is considered underweight, to get to a normal weight she would have to gain 11.75-27.12 kilograms (BMI Calculator, 2018). When asked if she felt good today she stated, “I have a stuffy nose, but that’s from allergies” (CP, 2018). CP Had just woken up, had her hair down and not brushed, and is wearing a blue shirt with writing on it and black yoga pants which were unwrinkled. General: CP is alert and oriented to person place and time, in a good mood and cooperative with answering questions. When asked if she had any problems sleeping CP states “I take a melatonin every night” (CP, 2018). Mom, VP, States that she hasn’t had any weight changes and doesn’t ever complain about not feeling good. After defining fatigue: CP states “I don’t feel like that unless I sleep bad” (CP, 2018).
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Child Health Assessment Pouliot3 HEENT: Head: CP denies headaches but VP states “When she gets a headache I give her 200 milligrams of ibuprofen and it usually goes away” (VP, 2018). Eyes: Denies blurry vision, pain, and discharge. CP states, “They itch a lot but that’s because of my allergies” (CP, 2018). CP wears glasses all the time while awake and can see far away when not wearing them. CP has worn them for four years. CP’s last eye exam was March, 2016. Ears: Denies drainage, tinnitus, or difficulty hearing; but states that, “they hurt sometimes with loud noises” (CP, 2018). Nose: Denies epistaxis but has reoccurring rhinorrhea. Throat: CP has no throat pain, mouth pain, or dysphagia & with mother’s permission lymph nodes were assessed and there was no swelling. When asked if CP’s gums bled at all even when brushing her teeth, she denied seeing any blood. Speech is clear, and CP has a good vocabulary for her age; face is also symmetrical. Neck: CP denies neck pain or stiffness and showed that she could freely move the neck without difficulty. Breasts: Denies tenderness even during menarche. VP states, “There has been a little bit of growth in the past few months” (VP, 2018). When asked if a bra was worn CP stated “yes” (CP, 2018), with red flushed cheeks. When asked about the type of bra CP was confused, so it was explained, the difference between a regular bra and a sports bra. CP states, “I wear both types but
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