Running head: CLINICAL MANAGEMENT PAPER
Clinical Management Paper
Honorata G. Shaw
University of Phoenix
NRP 524: Pediatrics and Adolescents Population
Carol King, MSN, CPNP
Beverly Vandercook, MSN, CPNP, CLC
Oct 30, 2004
Clinical Management Paper: Asthma
Name: D. A.
Marital Status: Single
Occupation: Student Source of Medical Care: Pacific Care HMO Healthcare Provider: RMC Informant: Mother & Reliable Self
Date of Visit: 10/06/2004 Chief Complaints: Nasal congestion, dyspnea, increase amount of coughing at night & early morning and during exercise, chest tightness for one week that started with persistent coughing while playing football. Complete History
• Mother – 49 years old, with allergic dermatitis on the right arm 4 cm length and 3 cm width. Regularly taking Synthroid 0.75 mg for hypothyroidism, denies headache or sinus problem. Mother and sister have the same parents. • Father – 50 years old, is unavailable, mother stated that he abandoned the family when D. A. was only two months old. Father and brother have the same parents. • Mother’s Pregnancy History – Mother had regular prenatal check up during pregnancy. G2 P1 Ab 1, spontaneous abortion at four weeks gestation on 1988. D.A., baby boy was delivered vaginally at 38 weeks gestation on October 29, 1989. Weight 6 lbs and 4 oz, 19 in. long at birth, mother does not remember the Apgar scoring but remember spontaneous strong cry. Circumcised second day after birth. FAMILY REVIEW OF SYSTEMS
|System |Mom | |B. Motor |Gross Motor - Can sits at about six months and crawling at nine months, stands with help or holding on the | | |furniture to stand up at 1 year. Unable to remember when he started walking, dressing self, and tying shoes. | | |Grandmother gave him a tricycle at 3 ½ years, he can pedal and ride it well. | | |Fine Motor – Pinching playmates at 1 year. Holds and drinks from cup around 2 years and can hold pencil at 4 | | |years. Using a spoon at 2 years. | |C. Language |His first word was Mama at age one year, can say “Mama dog” at around 2 years. Can speak and express wishes at | | |5 years. | |D. Toilet Training |In relation to Erickson’s developmental theory, at age 1 – 3, the child learns to control his body functions | | |and becoming independent in doing things himself. Started toilet training at age 2, by showing a 4 year old | | |cousin urinates on the toilet. Used baby toilet seat for bowel movement. Achieved by three years old. He had | | |fears of getting flushed into the toilet. | |E. Schools |School age at 6 years, he was able to dress himself and talked in Spanish around the family circle. He is an | | |average student, likes sports, and making friends with his peers. Well adjusted with his schools and his | | |friends that go in the same school district. Attended middle school (8th grade) at age 14 and has no problem | | |with his teachers. Presently, 9th grade and looking forward to attend high...
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