NR 602 Week 3 SOAP_Lataille_2020 – Chamberlain College of Nursing | NR602 Week 3 SOAP_Lataille_2020

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NR 602 Week 3 SOAP_Lataille_2020 – Chamberlain College of Nursing R. F., 17 months, M, Latino S. CC- Fever and rash HPI- Riley is brought in today for a complaint of fever and rash. The fever ... began 3 days ago and is of normal levels in the morning then gets as high as 103 to 104 degrees in the afternoons.  Riley has also had clear rhinorrhea and in the last 24 hours he has developed a red, diffuse rash to the torso and abdomen that does not itch and a dry cough in the last day. Mother reports he is drinking, but not as well as usual.  He did have a good wet diaper this morning, but is not really eating much and is not playing. Medications- Mother is giving OTC Robitussin cough and cold at 1 tsp last night and this morning. Liquid Tylenol ½ a tsp last night and this morning. Immunizations- Birth – Hep B, 2 months – Hep B, DTaP, HIB (COMVAX), PCV13, IPV, 4 months - DTaP, HIB (COMVAX), PCV13, IPV, 6 months DTaP, IPV, 6 months – DtaP, PCV 13, IPV, Hep B Allergies- Seasonal allergies (per mother) PMH- Born at 34 weeks gestation via cesarean section, weight. 5lb 1 oz. The mother developed preeclampsia and gestational diabetes. The mother quit smoking when she found out she was pregnant. Riley has allergies per mother. Social history- Lives with mother and maternal grandparents for the past 8 weeks. Their father is involved but lives 2 hours away in the state capital where he works. Family history- They are maternal and paternal smokers. The mother has been one since age 22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no diseases reported in either parent. Mother has a history with gestational diabetes and preeclampsia.  MGM has a history of hyperlipidemia, Type 2 DM, and Hypertension. They are Latin American in descent, emigrated from Cuba in the 1970s. MGF has a history of hypertension, hyperlipidemia, and an MI with stenting 2 years ago.  The mother has two siblings; one who died in an MVA 5 years ago at the age of 18 a younger brother, and an older sister who is 42 and lives in a large urban city in the Midwest with her family, and she is in good health. Other family members died of old age. She is unaware of paternal familial health history. ROS- Constitutional- fever x 3 days with some lethargy. - - - - - - - - - - - - - - - - - - - - - - - -- American Academy of Pediatrics (AAP). (2015). Allergy Tips. Retrieved from https://www.aap.org/en-us/about-the-aap/aap-press-room/news-features-and-safety-tips/pages/allergy-tips.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR:+No+local+token Arnold, D. H., Moore, P. E., Abramo, T. J., & Hartert, T. V. (2011). The Dilemma of Albuterol Dosing for Acute Asthma Exacerbations in Pediatric Patients. Chest, 139(2), 472. http://doi.org/10.1378/chest.10-2163 CDC. (2016). Scarlet Fever: A Group A Streptococcal Infection. Retrieved from http://www.cdc.gov/features/scarletfever/. Fenstermacher, K. & Hundson, B. T. (2016). Practice Guidelines for Family Nurse Practitioners (4th ed.). St. Louis, MO: Elsevier. Hamilton, J. L. & John, S. P. (2013, February 15). Evaluation of fever in infants and young children. American Family Physician, 87(4), 254-260. Hay, W., Levin, M., Deterding, R., & Abzug, M. (2014). Current diagnosis and treatment: Pediatrics (22nd ed.). Mayo Clinic. (2016). Roseola Symptoms. Retrieved from http://www.mayoclinic.org/diseases-conditions/roseola/basics/symptoms/con-2002351. National Institute for Health and Care Excellence (NICE). (2013). Feverish illness in children. Retrieved from http://guidance.nice.org.uk/CG160. Stiehm, R., Wood, R., Kaplan, S. & TePas, E. (2016). Approach to the child with recurrent infections. Retrieved from http://www.uptodate.com/contents/approach-to-the-child-with-recurrent-infections. [Show More]

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