Question

c) Simon's mother reports he is very healthy and comes from Chile. The family speaks Spanish at home, but English in public. The family lives in a large Victorian home, which they are renovating on weekends. Simon is 4 years old and responds appropriately to questions and is generally pleasant. He has no complaints of pain or health concerns. VS= 37 degrees C, P 86, R 20, BP 94/50 in left arm.  Ht. 41 inches. WT. 17.5kg. BMI 16.3. He is alert and cooperative, but is anxious as he comes into the room. His hearing is passed at 20 dB at 500, 1000, 2000 and 4000 Hz, but failed at 30 dB for the same Hz. He passed the DDST in personality, fine motor, and gross motor, but failed in the area of language.His immunizations are current. He has a potbelly and a wide base of support. His skin is intact with no lesions, but he has multiple bruises all over his body in various shapes and sizes. His visual acuity is 20/40 in bothe eyes and the corneal light reflex is symmetrical. His tympanic membrane is pearly grey and there is no foreign objects or drainage in the ears. The tonsils are quite large, and the teeth are without caries. The turbinates in the nose are bluish-purple and there is copious clear drainage. There is a pea in the left nostril. The lymph nodes are non papable. The chest circumference is appropriate for Simon and the chest ratio is 1: 2. The lungs have fine crackles in the left base.  Simon has a split heart sound in the pulmonic area that changes with respirations. There is also a venous hum in the mitral area. Bowel sounds are present in 4 quadrants and the genitalia are intact. Simon can walk into the examination room and is able to hop on each foot and touch each finger with his thumb.

What health concerns or abnormals are revealed in this exam? Identify at least 2 nursing diagnoses that are appropriate for Simon.

Answer 1

The abnormal health concerns are

• Presence of bruises all over the body is suggestive of physical or domestic violence
• Visual acquity of 20/40 is suggestive of near sightedness (The child can see object at 20 feet in place of a 40 feet distance)
• Enlarged tonsils is a signs of tonsilitis
• Presence of a foreign object in the nose
• Copious ckear secretion with cradles indicate respiratory infections

Nursing diagnosis

Altered nasal secretion related to blockage or presence of foreign object in the left nostrils as evidenced by clear ,copious secretion and pea

Goal:to remove the pea

Nursing intervention

• If it is at the tip of nose the child can be encouraged to blow out ,if not remove the pea with help of a suction device or instrument
• Assess patients vital parameters to prevent any complications
• Treat the infection by administration of medication as per order

Evaluation :The pea is removed

Impaired verbal communication related to delayed language development skill as evidenced by failing in the language DDST

Goal:to make the child enable communication

Nursing intervention

• Assess the underlying cause for child's late speech development, (ENT problems can be associated with decreased speech development )
• Conduct an hearing test, to assess the hearing capacity.Hearing loss can be the first reason for a child's delayed speech
• Encourage to participate in speech therapy clases

Evaluation :The child demonstrates adequate language development