Asthma Clinical Management
Running head: CLINICAL MANAGEMENT PAPER
Clinical Management Paper
Honorata G. Shaw
University of Phoenix
NRP 524: Pediatrics and Adolescents Population
Group: ON03FNP01
Carol King, MSN, CPNP Beverly Vandercook, MSN, CPNP, CLC
Oct 30, 2004
Clinical Management Paper: Asthma Name: D. A. Age: 15 y/o Race: Caucasian Sex: F
Religion: Baptist Marital Status: Single Occupation: Student Source of Medical Care: Pacific Care HMO Healthcare Provider: RMC Informant: Mother & Reliable Self Date of Visit: 10/06/2004
Chief Complaints: Nasal congestion, dyspnea, increase amount of coughing at night & early morning and during exercise, chest tightness for one week that started with persistent coughing while playing football.
Complete History
Family History • Mother – 49 years old, with allergic dermatitis on the right arm 4 cm length and 3 cm width. Regularly taking Synthroid 0.75 mg for hypothyroidism, denies headache or sinus problem. Mother and sister have the same parents. • Father – 50 years old, is unavailable, mother stated that he abandoned the family when D. A. was only two months old. Father and brother have the same parents. • Mother’s Pregnancy History – Mother had regular prenatal check up during pregnancy. G2 P1 Ab 1, spontaneous abortion at four weeks gestation on 1988. D.A., baby boy was delivered vaginally at 38 weeks gestation on October 29, 1989. Weight 6 lbs and 4 oz, 19 in. long at birth, mother does not remember the Apgar scoring but remember spontaneous strong cry. Circumcised second day after birth.
FAMILY REVIEW OF SYSTEMS
Family Members
|System |Mom |
|B. Motor |Gross Motor - Can sits at about six months and crawling at nine months, stands with help or holding on
Clinical Management Paper
Honorata G. Shaw
University of Phoenix
NRP 524: Pediatrics and Adolescents Population
Group: ON03FNP01
Carol King, MSN, CPNP Beverly Vandercook, MSN, CPNP, CLC
Oct 30, 2004
Clinical Management Paper: Asthma Name: D. A. Age: 15 y/o Race: Caucasian Sex: F
Religion: Baptist Marital Status: Single Occupation: Student Source of Medical Care: Pacific Care HMO Healthcare Provider: RMC Informant: Mother & Reliable Self Date of Visit: 10/06/2004
Chief Complaints: Nasal congestion, dyspnea, increase amount of coughing at night & early morning and during exercise, chest tightness for one week that started with persistent coughing while playing football.
Complete History
Family History • Mother – 49 years old, with allergic dermatitis on the right arm 4 cm length and 3 cm width. Regularly taking Synthroid 0.75 mg for hypothyroidism, denies headache or sinus problem. Mother and sister have the same parents. • Father – 50 years old, is unavailable, mother stated that he abandoned the family when D. A. was only two months old. Father and brother have the same parents. • Mother’s Pregnancy History – Mother had regular prenatal check up during pregnancy. G2 P1 Ab 1, spontaneous abortion at four weeks gestation on 1988. D.A., baby boy was delivered vaginally at 38 weeks gestation on October 29, 1989. Weight 6 lbs and 4 oz, 19 in. long at birth, mother does not remember the Apgar scoring but remember spontaneous strong cry. Circumcised second day after birth.
FAMILY REVIEW OF SYSTEMS
Family Members
|System |Mom |
|B. Motor |Gross Motor - Can sits at about six months and crawling at nine months, stands with help or holding on
References: Boynton, R. W., Dunn, E. S., Stephens, G. R., & Pulcini, J. (2003). Manual of ambulatory pediatrics (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Hatfield, N. (2003). Broadribb 's introductory pediatric nursing (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Lin, T. L., & Schaiff, R. A. (2002). The Washington manual of ambulatory therapeutics. Philadelphia, PA: Lippincott Williams & Wilkins. Polin, R. A., & Ditmar, M. F. (2001). Pediatrics secrets (3rd ed.). Philadelphia, PA: Hanley & Belfus, Inc..