Hello all! I am currently trying to create a scholarly paper based on my SOAP note based on the following case study scenario (our scholarly paper requires us to add additional things we as nurses could ask the client or procedures we would need to do for assessment that is RELATED to the "topic" or "main issue" of the case scenario... Says my teacher.. .
PLEASE! Critic my SOAP note, tell me what I missed, etc. Your help is greatly appreciated!
CASE STUDY SCENARIO:
"A 17 month old male toddler is due for a checkup and is brought in by his parents. As the practical nurse on duty at the clinic, you are required to perform a physical assessment. At the start of the assessment, the toddler is crawling around on the floor while his parents are preparing a snack of Doretto chips and bottle of juice substitute. You notice that the toddler's weight is written down on his chart as being 32lbs, and has all up-to-date immunizations. The last visit made was at the 1 year (12 month) checkup and it is documented that immunizations are up-to-date. The parents state the child insists on being carried and if he is left to crawl around for too long, he would roll onto his back and start to cry uncontrollably. The child begins to cry as you are talking to the parents because he has just finished his beef jerky."
My SOAP Note..
S- 17 month old toddler is brought in by his parents for his checkup. Parents state the child "insists on being carried and if he s left to crawl around for too long, he would roll onto his back and start to cry uncontrollably."
(Additional subjective questions to ask the parents include socioeconomic status, ethnicity, family history of illness, maternal gestation health (any issues with alcohol or drug use), child's usual feeding patterns, what his meals and snacks usually consist of, how his bowel movements are, allergies or medications of the child, how much food does the child usually eat, ask the parents for a 24 hour recall of all meals and snacks eaten by the toddler, if the child has developed any motor or social skills since the one year mark, if the parents have tried to encourage standing and walking for the child, their methods for dealing with tantrums and what the parents think a healthy weight for the child should be.)
O- The child is a 17 month old toddler, weighing 32lbs and has all immunizations up-to-date. The child is observed to be crawling around the examination room while both parents are preparing a snack of Doretto chips and juice substitute. When speaking to the parents, the child begins to cry because he has just finished his beef jerky.
(Additional objective data requirements (depending on toddler's temperament- less intrusive to more intrusive) include the "head to toe" assessment to identify any abnormalities such as muscle dystrophy that is more prevalent n male toddlers and may cause fatigue and irritability of the child (and cause delay of standing and walking), "head circumference" measurement, measure height and weight (again) to calculate if the child is within a healthy BMI range, Vital signs (BP, P, T, SpO2, R), and assess ability for standing, walking, speaking (a few words), etc to assess milestones met.)
A- Lack of nutritional requirements and independent motor movement for healthy growth and development for toddler R/T lack of knowledge from parents AED irritable behavior from child when crawling alone for too long- and "insists on being carried"- lack of independent movement.
P- Educate parents on nutritional values and requirements for every meal and promote more varieties of fresh fruit, vegetables, meats, dairy, etc. refer to a child dietitian to help parents budget healthy meals and snacks that can be affordable depending on economic status.
Educate parents on outdoor and indoor activities and games to help encourage the child to stand and take steps on their own and develop confidence to take on a more "independent" movements.
Educate parents to record meals and snacks in food dairy to keep track of healthy eating and amounts, as well as measuring weight and height (horizontally, until the toddler can walk)
Educate parents about positive parenting styles for toddler tantrums (ignore, or providing praise for good behaviour or acceptable punishment for bad behaviour)
Thank you again for taking the time to read everything! I'm not familiar with toddler development, but I did some research, and added procedures I would need to do... Please let me know what you think. Thanks