pediatric care plan
S- Amy is an 18-month-old infant presented for follow up with mom. Ms. Ana speaks Spanish and Ms. Katherine from the GAIL program accompanying us as an interpreter. Ms. Ana said Amy was taken to the doctor on 10/27/19 for and was diagnose with asthma. Mom said Amy was first notice to have asthma at 6 months and 9 months, but the doctor said she was still little so now she is diagnosed with being an asthma patient. Mom said the first time Amy had an asthma attack her lips turn blue and she would not breath and this is what happen when she took her to the pediatric. She was giving Acetaminophen 6ml by mouth every 4-6 hours as needed for 3 days, pain and fever, Ibuprofen 100 mg/5 ml, 6 ml every 6 hours as needed for 3 days for pain or fever, Albuterol sulfate HFA inhalation Aerosol 90 mcg inhale 2 puffs every 6 hours as needed, Optichamber diamond W-med mask, use with inhaler, Hydrocordisone 2.5% use 2 times per day on dry itch rash for up to 1 week, Ear drops ( Carbamide Peroxide 6.5%) earwax removal aid. Mom said Amy continue to development and grow. Amy eating habit is good and she is improving in her potty training. Mom said she is watching two of Amy cousins today and they are getting alone well but one of her cousins is not feeling well.
O- Upon enter the house Amy was sitting in her highchair and her cousins were on the floor playing but she was very happy to see us and waving to us. Amy was comfortable during her assessment today without her mother holding her. Amy was happy showing us her sippy cup, chair and toys. After the assessment she got on the floor to play with her cousins.
A- Respiration is 32 bpm, BP 68/52, temp 95.3, heart rate = 114, normal breathing sounds, lungs are clear with no sound of wheezing or distress. Height is 31 inches, weight= 27.4 lb, Head Circumference = 20 inches. Bowel sounds are active in all four quadrants. Patient skin appears to be normal. Hearing is active, anterior and posterior are close with no bulging out.
P- Advise mom to administer inhaler before Amy leaves the house to prevent asthma attack. Advice to keep the sliding open to a minimum and keep the highchair away from the open door. Advice to keep the house dirt and cluster free to minimize asthma triggers. Mom is very receptive to keeping her daughter safe. Encourage to administer all medications as directed. Encourage mom to put on educational shows when Amy watch TV. Next Appointment is November 14, 2019 at 10:00am.
