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Case study information
Jadon is a 14 year old boy. He lives with his aunt Dianne 43 years old. Jadon’s mother died at the age of 34 years of mouth cancer when he was 3 years old. His father died at the age of 31 heart attack (arteries was 80% clogged). His grand father died of heart attack at age 40 and his uncle (father’s brother) died of heart attack at age 37. Jadon has no known current medical problems but he use medication for ADHD, has learning difficulty and behavioural problems. No allergies, exercise regularly plays soccer and football, has all immunisations. Eats lots of Macdonald’s burgers and sleeps well.
Jadon was adopted by his Mom’s sister Dianne when his mom died he was 3 years old. He was very traumatised at that stage. Dianne divorced her husband when Jadon was 6 years old. Dianne has 3 children aged 4, 8 and 12 who live with their dad as he got custody at the time of the divorce because Dianne has an alcohol aIDiction. Diane has lost her drivers licence once for drinking and driving. Jadon has no other brothers and sisters. He visits his grandmother (Dianne family her (brothers and sisters) over weekends and plays with his cusions who all enjoys drinking. He stays by himself at home after school. He cleans the house and feeds the two dogs after school.
Since he is 12 he hangs out with friends more and gives Dianne attitude problems. He no longer confided in her he depends on friends. Sometimes rebellious and threatens to go live with his grandmother to get his way.
Assessment #1 Health Assessment Report Assignment
Weighting: 40%
Due Date: 22th of August 2013 by 1700
HICYP Assessment 1 Health Assessment Report (Graded)
This assessment has been designed to assist you to develop assessment skills, analyse the information and then write a report in a concise, accurate and coherent manner.
Objectives assessed
¢ CO2. Differentiate between the assessment of infant, children and young people taking into account expected growth and developmental age and stages
¢ CO3. Demonstrate the ability to conduct a child health assessment applying knowledge of expected growth and development
¢ CO6. Apply knowledge of the cultural needs, rights and expectations of infant, children young people and their families within a legal and ethical framework
Completing the Assignment:
Type your answers onto the template below as per the following instructions:
In Section 1 (250 words) enter the raw data (your recorded observations and measurements) from your assessment of the child. Short phrases or dot points are suitable in section one. No referenced material can be included as data.
In Section 2 (400 words) write a description about how you would communicate and establish a therpeutic relationship with a child of your chosen age group. Please include appropriate touch, body language, eye contact, verbal and non verbal communication, legal and ethical issues and cultural competence.
In Section 3 (1,000 words) provide a referenced analysis and interpretation of the health assessment data using support from at least 4 aIDitional peer reviewed journal articles that you have researched and located (2008 or later). (These are NOT from set course readings).
Each topic, within the health assessment, must be analysed and interpreted by comparing it to Normal and Abnormal Findings for each of the assessment items. You will also determine what the future health implications may be for this child when comparing the data to the research evidence. Conduct the child health assessment using the areas learnt over the first 6 topics of the course. Physiological, psychosocial and emotional development should be assessed as well as general health and well-being. You will not be making recommendations in this assignment.
Physiological
¢ Past medical history
¢ Family health history (relevant to child ie Asthma)
¢ Current health status (Health maintenance, medications required, Allergies, immunisations, safety measures used appropriate to age group, activities and exercise, Nutrition, sleep)
Psychosocial/emotional
¢ Family structure
¢ School or child care arrangeements
¢ People the child spend time with (family and Friends)
¢ Description of household activities
¢ Assess emotional development pertinent to the child’s age and developmental status.
Review of Systems
¢ General Growth and development (age appropriate sleep, nutrition, physical activity, screen time, allergies, head circumference, weight, height)
¢ Skin (temperature, texture, lesions, rashes, bruises, Mongolian blue spots)
¢ Hair and nails (thin, thick, a lot or less, scalp sores)
¢ Head (fontanel’s where appropriate, symmetry of face)
¢ Eyes (eye colour, eyelashes, pupils, eye muscles)
¢ Ears (external structures, hearing issues, startle reflex in a infant)
¢ Nose (structure of the nose, Discharge evident)
¢ Mouth and throat (mucous membranes, teeth, gums, tongue, lips, discussion of oral hygiene habits)
¢ Cardiac (pulse rate, apical pulse for infants)
¢ Chest and respiratory (respiration’s, Inspiration and expiration’s, breath sounds)
¢ Gastrointestinal (discussion of bowel habits, pain after eating, bloating, gas, constipation)
¢ Urinary (frequency of urine output, colour)
¢ Musculo-skeletal (posture and spine alignment, legs and feet particularly in the toIDler, gait, coordination)
¢ Neurologic (communication, Language development, reflexes in infants)
Be aware to discuss the practice of Inspection, Palpation and Auscultation in your assessment of your child.
Ensure you plot head circumference, weight and height/length on the age appropriate percentile charts and attach these to your assessment. Percentile charts can be found in Appendix 7 of the custom text book for this course.
Template for this assignment
Health of Infants, Children and Young People
Assignment 1: Child Health Assessment Report
SECTION 1: Child Health Assessment Pro Forma(300 words)
Conducted by Student Date
Child’s first name Jadon Age 14
Parent Consent Gained Dianne Gender Male
PHYSICAL ASSESSMENT
Height 158cm Weight 55kg H/C 56cm
Temperature 37 Pulse 67 Respirations 14 bpm
Physiological Findings Writer Please help me with this information only 3 4 lines dot point
Psychosocial/
Emotional Development Writer Please help me with this information only 3 4 lines dot point
General Assessment
Skin Smooth, pink normal (Writer is this the way to describe it)
Hair and nails Brown thin hair, nails short and clean Writer is this the way to describe it
Head Writer I don’t know how to describe it he has normal head please help
Eyes Pupils a size 3 brown eyes Writer help me here
Ears Normal earlobes no hearing problems Writer help me here
Nose Small nose no breathing problems Writer help me here
Mouth and throat Normal Writer help me here to describe it
Cardiac
Normal Writer help me here
Chest and Respiratory Breathes normal no known chest problems Writer help me here
Gastrointestinal 3 Normal bowel movements a day Writer help me here
Urinary 4 normal light yellow urine a day Writer help me here
Muscolo-skeletal Normal Writer help me here
Neurologic Normal Writer help me here
Record any other comments made by the child about their general health status ie Allergies
None
SOCIAL HISTORY
Age appropriate sleep
Sleeps well about 12 hours a day Writer help me here
Age appropriate Nutrition
Eats lots of junk food macdonals no healthy diet Writer help me here
Age appropriate physical activity
Soccer and football twice a week Writer help me here
SECTION 2: Discuss how you would communicate and build rapport with a child of your chosen age group. (400 words)Include in your discussion the use of body language, eye contact, appropriate touch between nurse and child, cultural considerations you have made, listening techniques and legal and ethical issues associated with a child health assessment. This part of the assignment should not be in the first person. In text reference and page number
SECTION 2: Analysis and Interpretation of the Assessment Data (950 words)
– within your referenced discussion identify expected parameters and normal and abnormal findings of the child’s data from section one. Discuss future health implications for the child in relation to health assessment data.In text reference and page numbers
