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Nutritional Evaluations

Nutritional Evaluations

Sample Answer 

Nutritional Evaluations

From the information provided in the HPI and PMH, the infant has maintained her home routine according to her parents’ reports. Additionally, the parents are usually available to offer any support the child might need at any time. The child is generally well-developed and nourished. The vital signs are also normal. However, she has started kindergarten and interacts with other children. She also sleeps a little under nine hours, which could deprive the toddler of about an hour or less of sleep every day (Thomas and Burgers, 2018). Her engagement in the soccer league also requires training and interaction with other children. The nightmares could manifest due to her interactions with her new environment since she started experiencing them after kindergarten.

The possible diagnoses include Post Traumatic Stress Disorder (PTSD), sleep disorders, and stress or anxiety in the toddler. Her interaction with the new environment might interfere with her usual routines, including her sleeping patterns and energy levels. She could be getting too tired from the soccer league or not getting sufficient sleep, which is critical to her early development (Ophoff et al., 2018). The episodes she experienced could be manifestations of the events during her day.

The priority diagnosis for the nightmares could include a sleep study, during which the patient is required to spend a night in the laboratory to monitor the brain waves, heartbeat, breathing, eye movements, muscle tension, blood oxygen levels, and leg movements, among others to determine the underlying conditions that trigger the nightmares. Since nightmares do not necessarily require treatment, the underlying mental and medical conditions can be addressed, and possible stimulants such as caffeine can be controlled or eliminated from her diet.

References

Ophoff et al. (2018). Sleep disorders during childhood: a practical review. European journal of pediatrics177(5), 641-648.

Thomas, J. H., & Burgers, D. E. (2018). Sleep is an eye-opener: Behavioral causes and consequences of hypersomnolence in children. Paediatric respiratory reviews25, 3-8.

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Question 


Nutritional Evaluations

Discussion 4 – Nutritional Evaluations

Discussion Prompt:

  • Please evaluate the subjective and objective information provided to you in the file below.
  • First part of the discussion board is to identify all pertinent positive and negative information.
  • Document any other information you would want to obtain?
  • Then create a differential diagnosis list with at least 3 possibly actual diagnosis based on your findings.
  • Second part is to create a plan utilizing clinical practice guidelines for the priority diagnosis.
  • Include APA in-text 2 scholarly citations and provide full reference citation at the end of the discussion.

***File below:

NU632 Unit 4 Discussion Case

Nutritional Evaluations

Nutritional Evaluations

C.C. Nightmares

HPI: M.M. is a 5 y.o. F who present to HU clinic with her mother for nightmares. She was recently evaluated at the clinic 1 month ago for her 5-year-old well child checkup. Developmental, behavior showed no concerns at that visit. Mother reports nightmares started 3 months ago but now they are occurring more frequently at least twice per week. Mother reports M.M. going to bed around 9PM and normally by 11PM she is up screaming, confused and clammy. Mother and father are unable to get her to calm down during these episodes. M.M. will eventually calm down and fall back asleep. She usually wakes up at 6:30 AM to start to get ready for school. Mother denies any recent changes in her home life, she did start kindergarten and also a soccer league (practice twice a week for an hour with 30-minute games on the weekend). M.M. reports not remembering these episodes. She reports still enjoying school and has made a new friend name “Jaden.” They are in class together and on the same soccer team.

PMH: Born at 39 weeks’ gestation via cesarean section for being in a breech position. There were no complications at birth. There were no complications throughout the pregnancy. The infant’s mother denies tobacco use, drug use, or alcohol use during pregnancy. The infant was breastfed.

Allergies: No known drug allergies

Medications: Disney Princess Gummy Vitamin

Social History: The child lives with her mother and father who have been married for 2 years. Both parents work full-time. She started public school two months ago which is full day kindergarten. Father Vapes in the home. Both parents report social drinkers on the weekend, “couple of beers with dinner.” There are no firearms in the house.

Family History: Mother and father deny any significant medical history. Health Maintenance/Promotion: Immunizations are up to date including this season’s flu vaccine.

Review of Systems

General: Denies any concerns, unexplained fevers, or growth and developmental concerns. Skin: Denies any rash, lesions, or concerns with eczema. Head: Denies headache, trauma or falls. ENT: Denies any concerns with ears, nose, or throat. Neck: Denies pain with ROM neck. Denies masses or lumps. CV: Denies any chest pain, cyanosis, heart racing or sweating. Lungs: Denies any cough, congestion, wheezing, or difficulty breathing.GI: Denies food intolerances. Denies weight loss, nausea, vomiting, constipation or diarrhea.GU: Negative for burning or blood in urine. Musculoskeletal: Denies pain, trauma, and numbness. Neurological: denies changes in senses. Psych: Denies difficulty concentrating, tearful episodes, anxiety or seclusion. Endocrine: Denies increase thirst or urination. Hematologic: Denies bruising or bleeding.

Objective VS: Temperature: 99.2F, 99/59, HR: 89, RR: 22, 100% on RA, Ht: 55in (93.52%), Wt.: 97 lbs. (98.3%), BMI: 22.54(97%).General: Well developed, well-nourished and hydrated, no apparent distress. Appropriate dressed. Skin: No evidence of rash or lesions. Head: Normocephalic. Eyes: The lids and conjunctiva are normal. Pupils are irises are normal fundoscopic exam reveals red reflex present bilaterally. ENT: Normal external ears and nose. Normal external auditory canals and tympanic membranes. Hearing is grossly normal. Dental caries B, C, M, L. Mild erythema and swelling gingivae. Oropharynx: normal mucosa, palate, and posterior pharynx. Neck: Supple and no lymphadenopathy.CV: Normal rate and rhythm. Normal S1 and S2 heart sounds heard on auscultation with no S3 or S4. No murmurs. Femoral pulse 2+ bilaterally. Lungs: Normal respiratory rate and pattern with no apparent distress. Bilateral breath sounds clear on auscultation without rales, rhonchi, or wheezes. Abd: Normal bowel sounds. No masses or tenderness or organomegaly observed. MSK: Grossly normal tone and muscle strength. Normal range of motion in extremities.

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