S: Assessment conducted on 3- yr. old African American Payton Bailey who is a male in presence of his mother Rey Bailey. The mother stated she is pregnant and expecting baby on August 08/08/2019. Payton has speech delay and barely speaks one word. She stated she is working on to schedule with his speech therapist. She stated Payton does not complain of eating and prefer regular meal. Payton does not have any allergies. Code is full code. Mom stated his weight is 38 lb. from last month doctor visit. Payton loves to play at home with his 4-yr. old sister, but not with his other friends. He is on toilet training currently. Mother indicated he is not in day care program yet and planning to enroll him in head start program next year. Mom stated he is up to date on immunization record. Mother stated, Payton and his 4-year sister were adopted by her and their biological mother is her own sister. She is Ex-Military and goes to full time school. She gets some allowance to pay her school fee from her military service fund. Her mother and 13- year are her support system at present. She is planning to get divorce quite soon. Mom just recently moved to the new state and it’s still adjusting with the children. She also has her mother and a younger brother who usually assist with taking care of the children for her. She also stated that she goes to school and stays in the house most of the time.
O: Clean outside environment, age-appropriate toys were provided; Presence of age-appropriate toys. The children were still sleeping upon arrival. The living room was a little messy probably because of the children playing around the night before. The kitchen was well put in order. The children were playing with their new toys. The children were very friendly after waking up. TV in the living room for children to watch.
A: Facial features symmetric; eyes and nose symmetrical; no lesion on the head, skin is soft and intact and appropriate skin color pertain to her race. Educated Mom on using booster car seat. Educated mom to find speech therapist for Payton.
Capillary refill: less than 2 sec. teeth have no visible caries. No issue with walking independently by placing both feet on each step; read book and point picture on the book.
Pulse Rate: 90 bpm, regular
RR: 22 /min Height: 38.5 inches. Breath sounds clear bilaterally. Bowel sound active on four quadrants.
Age-appropriate activities: push and pull toy, play with blocks, play parallel with his sister.
***Important points– Please i need someone who is knowledgable about doing a nursing care plan. This care plan is on the three year old P.B. This is a pediatric care plan. Please refer to a nursing diagnosis book or trusted source (Each nursing Diagnosis needs to have 3 OUTCOMES. With 3 outcomes a total of 9 interventions. State whether depended or independent intervention and goals for each outcomes (met or unmet). References at the end.
So to conclude. 3 nursing diagnosis. 3 nursing outcomes per diagnosis, 9 interventions per diagnosis for a total of 27 interventions. ***Please any questions let me know. (FOLLOW the rubric please. Very Important.) I will attach a sample care plan i did before below But please use the Pediatric care plan i attached below. (Don’t forget the SBAR assignment too.)