Nursing SOAP Notes

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SOAP notes are the submissions that help to reflect on the Practicum experiences and also connect the experiences to the classroom notes. The major purpose of having SOAP notes in the nursing profession is to document the patient care throughout the management plan of an illness. SOAP notes is an acronym that refers to the terms Subjective, Objective, Assessment, and Plan as well as the Reflection notes. The subjective component refers to the patient’s description of the current condition in a narrative form. The objective component refers to the documentation of the traceable facts about the status of the patient. The assessment component refers to the medical diagnosis for the medical visit. The plan describes the action taken by the care provider to treat the patient (Seidel, Ball, Dains, Flynn, Solomon & Stewart, 2011). The essay provides SOAP Notes submission for a child one year with autism.

Subjective

Johns’ parents visited the hospital with their son after making several observations about his development which were uncommon. John is a healthy child aged one year whose parents have the worry of his development because he does not behave similarly to his older brother when at his age. He does not play and also never mimics some expressions and gestures. The parents try to entice and also engage him with good toys, songs, and even games, but he seems to lack interest in them. He is not amused and maintains a gloomy face. It is challenging for him even to make an eye contact and despite his hearing being normal, he makes no noises or response when called by a name similar to other babies. The observations were the reason for visiting the hospital.

 Objective

Following the details provided by the parents about the child, it was necessary to conduct a physical examination to identify the cause of the behavior. The observations made regarded checking whether the child made an eye contact, made a smile, responded to her name, and followed gestures when pointed things out, made noises to get attention, reached out for support, and also followed objects visually. Other physical assessments entailed the measurement of weight and height to check for normal growth, head circumference measurements to determine the head size, examination of the face, arms, and legs to look for birth defects as well as the routine tests for assessing the developmental delays. The findings from the physical examination revealed that the child had challenges in responding too many of the attempts to entice him through vision, audio, or the physical movements. He seemed insensitive to the eye contacts, smiles, name calling, gestures, and noises made around him. The assessment of the hearing ability was normal, but he did not respond to the sounds made. The weight and height were normal, but the head circumference was abnormal. It was likely that the child presented has growth and development issues that required a further assessment for diagnosis.

Assessment

After careful assessment of the physical exam findings, the likely differential diagnosis for the child was autism, Down syndrome, and Fragile X syndrome. Autism is a type of development disorder that manifests in the early childhood and characterized by abnormalities in the social interactions, aberrant, communication problems, and restricted behaviors, interests, and other activities. For Down’s syndrome, there is extra genetic material that causes delays in the development of a child both mentally and physically. The physical features associated with the condition vary from one child to another, hence necessary to detect in the early stages for preventive measures to be taken (Hagan, Shaw, Duncan, 2008). Fragile X syndrome is a genetic condition that results in a range of developmental problems that include learning disabilities and cognitive impairment. The disorder usually affects males than females. The primary diagnosis for the condition presented by the child is autism due to certain defining factors. Autism manifests in early childhood and is evident by the signs and symptoms exhibited by the child. The disorder has an association with developmental regression, the absence of pointing ability, abnormal reactions to the environmental stimuli, the absence of smiling and symbolic play, as well as abnormal social interactions (Burns, Dunn, Brady, Starr & Blosser, 2013). Thus, the likely diagnosis is autism.

Plan

The plan for diagnostics and the primary diagnosis involved testing the child for the delayed development and growth by the use of height and weight measurements, head circumference, and examination of the face, arms, and legs to look for birth defects. The treatment and management plan for autism is intensive and comprehensive that requires the collaboration of the family and the professionals. The recommended treatment plan to the child involved the use of behavioral, educational, and psychological components. The child was scheduled for a therapy that required multiple hours per week to address the behavioral, developmental, and educational goals. The child was also put under medication in conjunction with the therapy program. The drug used was risperidone under a low dose alongside the therapy. An alternative drug for treatment of autism would be aripiprazole. The reason for the choice of the treatment method is the perceived effectiveness when both the pharmacological and the non-pharmacological methods are used (Warren, Veenstra-VanderWeele, et.al., 2011). It was necessary to schedule a follow-up plan and referral to assess the progress of the child towards autism recovery.

Reflection Notes

I found it appropriate that children are assessed for multiple disorders at an early stage of their development to identify the inherent likely disorders. I was amazed to realize that a child may appear normal, but have certain developmental disorders that define their behavior. I think that I would evaluate a similar patient differently by focusing on the progress of growth of the child from prenatal stages to the postnatal stages for consistency. A correlation of the signs and symptoms of the developmental delays would help in an early diagnosis of the disorder.

 References

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric primary            care (5th ed.). Philadelphia, PA: Elsevier. Chapter 7, “Developmental Management of           School-Age Children” (pp. 92–109)

Warren, Z., Veenstra-VanderWeele, J., Stone, W., Bruzek, J. L., Nahmias, A. S., Foss-Feig, J.      H., … & Surawicz, T. (2011). Therapies for children with autism spectrum disorders

Hagan, J. F., Jr., Shaw, J. S., Duncan, P. M. (Eds.). (2008). Bright futures: Guidelines for health   supervision of infants, children, and adolescents (3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics. Review: “Promoting Physical Activity” (pp. 147–154)

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011).      Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Mosby. Chapter 26,             “Recording Information.



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