Submit the answers to questions 1-7 for your grade (1-2 pages)
A 2-month-old male presents for a well-child visit in Alaska. This is the first time you see this infant. You ask the mother if they have been seen elsewhere for records. She states, “no, Timmy was born in Texas as a home birth and we moved here when he was 3 weeks old.” She continues to state, “he seems so small and I don’t know if he has gained weight, when I kiss him he tastes salty.” You ask about feeding and the mother states that the infant is breastfeeding but gets tired after about 5 minutes.
You proceed to get his VS and measurements. VS are 98.4F, RR 66, HR 144, O2 sat 92%. Weight 2.3kg, Height 21 inches, OFC 14 inches. When you plot his measurements on the growth chart he is below the 10th percentile for all measurements. Mom states “he was at the 50th percentage for everything when he was born”.
1. What are your 3 priority concerns? List in order of priority and provide the rationale
You continue on your assessment and find the following:
Neuro/development – infant’s tone is appropriate, unable to lift head when prone,
HEENT – Fontanelles are soft and flat, head symmetric, eyes and ears are symmetrical, eyes track mother as she moves around the room, the nose is midline, no nasal flaring
Respiratory – Symmetric chest movements, diffuse wheezing bilaterally, no accessory muscles used.
Cardiac – S1, S2 heard, no murmurs, cap refill <3 seconds
GI – bowel sounds normoactive, distended abdomen, diaper change found greasy, foul-smelling stool.
Musculoskeletal – Full ROM
Integumentary – pink, moist, and intact
GU – genitals intact, no rashes, wet diaper
2. What is alarming to you at this point and why? Use a reference to support your concern
You report your assessment to the Pediatrician, include objective/subjective data, development, vital signs, appropriate measurements, and any other assessment findings you would like to include.
3. What diagnosis do you suspect for your patient?
4. What labs and diagnostic tests do you anticipate will be ordered?
5. Document your assessment for this patient
6. What is your priority SMART Goal?
7. List 2 interventions you will do to help the patient/family meet the SMART goal. Provide an evidence-based rationale for each intervention.
