ped s clinical sbar wellchild paper care plan

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ped s clinical sbar wellchild paper care plan

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2. Well Child Developmental Assessment Paper

3. Care Plan

Please use initial only and below is a soap note of the child I want to use.

S- T.S is a 12-month-old African American boy presented with the father and sisters for follow up visit. He was sitting in his highchair in front of the TV watching an educational children program with his sisters. Dad open the door to let us in the apartment. T.S was very happy to see us and extended his hands so I could get him out of the highchair when he saw us. Mom had just left for work according to dad. Dad said the Gtube site is healing well and the band aid has been removed. Dad said T.S is still using the nebulizer twice a day for allergy as advice by his pediatrician. Dad said he is considering taking T.S to the daycare from Monday to Friday now because he has a lot to do even on Thursday which was the day the children did not go to the daycare because dad was home.

O- The house is very clean with some toys on the couch in the living room. T.S was clean and sitting in his highchair when we got there but later began moving around the apartment when he was taken out of the chair for his assessment. His sisters were present and tidy. T.S Gtube site is healing well with no sign of infection. The band aid has been removed and the site is left open to air. The children are happy and playing along. T.S is very active around his family.

A-Respiration is 32 bpm, Temp 98.5, Heart rate – 120, normal breathing sounds, lungs are clear with no sound of wheezing or distress. Height was 30.5 inches, weight – 10.5kg, Head Circumference = 19.6 ins, Bowel sounds are active in all four quadrants. Patient skin appears to be normal.

P-. Dad advice to get T.S to drink more water. Encourage Dad to make sure T.S take nap during the day.


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