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support@onlinenursepapers.com Zachary LaFontaine Infant Well Visit Shadow Health Transcript
Greeting:
Medical Professional: Good morning. How are you?
Patient: Hi.
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Medical Professional: You have a beautiful baby.
Patient: What brings you here?
Patient’s Visit:
Medical Professional: We’re here for Zachary’s wellness visit. It was hard to work it into our schedule, but I know it’s important.
Patient: I am glad you could make it.
Medical Professional: I appreciate it. How is Zachary doing?
Patient: Zachary is a very happy baby. He smiles quite a bit. It’s nice coming home from school or work to see him.
Medical Professional: How old are you?
Medical Professional: Where do you work?
Nurse-Sensitive Quality Indicator: Nursing Care Plan Strategies to Address Falls
Medical Professional: Who do you leave him with when you work?
Medical Professional: Who do you leave him with when you work?
Medical Professional: It is important to interact with the baby.
Patient: Ok, that sounds good. How is he eating?
Patient: Zachary only gets breastmilk, no formula at all.
Medical Professional: How often do you feed your son?
Patient: I try for 2-3 hours during the day and 3-4 at night. We don’t always manage it, though.
Medical Professional: How is he sleeping?
Patient: Zachary always has a hard time sleeping on nights I come home late, Tuesdays and Thursdays. It’s hard on me because I can barely get any sleep those nights, and I don’t get much as it is. I wake up early for class after taking care of Zachary all night. It’s a lot.
Medical Professional: I understand it could be a lot. I am glad you are taking care of Zach.
Patient: I appreciate that.
Medical Professional: What are your goals for breastfeeding?
Patient: I want to only breastfeed Zachary. I know formula is an option, but that would be a last resort. I want to focus on giving my baby breast milk.
Medical Professional: That is great. Breast milk is the best for a baby.
Patient: I understand.
Medical Professional: Where does your son sleep?
Patient: Zachary sleeps in a bassinet at night or sometimes in his cradleboard. He’s always swaddled and always on his back. I keep the bassinet empty and in my room, so I’m always nearby. I’m really afraid of SIDS or anything like that, so I did a lot of reading on sleep safety.
Medical Professional: How is your son sleeping?
Patient: Zachary always has a hard time sleeping on nights I come home late, Tuesdays and Thursdays. It’s hard on me because I can barely get any sleep those nights, and I don’t get much as it is. I wake up early for class after taking care of Zachary all night. It’s a lot.
Medical Professional: It is important to supervise sleep for safety.
Patient: Good to know.
Medical Professional: What do you know about developmental milestones?
Patient: Milestones? Zachary squirms around a lot and smiles.
Medical Professional: Does your son make gestures?
Patient: He coos and burbles. It’s pretty cute.
Medical Professional: Are you reading books?
Medical Professional: Are you learning about kids?
Medical Professional: Are you learning about your son?
Medical Professional: Does your son track you with his eyes?
Patient: He does, yes. He also loves staring at strangers. He seems curious about everything.
Medical Professional: Does your son follow the sound of your voice?
Patient: Zachary will look at me if I talk to him. Sometimes he’ll stare at me or make a little coo.
Medical Professional: Are you depressed?
Patient: Well… I don’t know? I don’t think I’m technically depressed, but I’ve just been so busy and tired that I barely have time to reflect on myself like that. I feel overwhelmed. I don’t know how I am going to handle everything and raise Zachary. But I’ll figure it out. I have to.
Medical Professional: Postpartum depression is a frequent finding. Please let us know if anything we can help with.
Patient: Alright, thanks.
Physical Examination:
Medical Professional: Inspected head circumference growth chart.
Medical Professional: Inspected weight and length growth chart.
Medical Professional: Inspected head circumference growth chart.
Medical Professional: Inspected nose.
Medical Professional: Inspected ears.
Medical Professional: Frenulum attached middle of mouth floor. Appropriate length and movements. Appears thin. Palate meets at the midline completely. Tongue appears smooth and uvula located at midline.
Medical Professional: Inspected ears.
Medical Professional: Frenulum attached middle of mouth floor. Appropriate length and movements. Appears thin. Palate meets at the midline completely. Tongue appears smooth and uvula located at midline.
Medical Professional: Inspected skin.
Medical Professional: Inspected skin: diaper area.
Medical Professional: Inspected genitalia.
Medical Professional: Assessed Musculoskeletal Barlow and Ortolani.
Medical Professional: Assessed eyes: pupils.
Medical Professional: Assessed red reflex.
Medical Professional: Assessed Eye Tracking.
Medical Professional: Assessed extremities.
Medical Professional: Assessed grasp: Able to lift shoulders off table with expected head lag.
Medical Professional: Assessed Moro Reflex: Infant briskly abducts arms and legs symmetrically, then brings legs up against trunk.
Medical Professional: Assessed Moro Reflex: Infant briskly abducts arms and legs symmetrically, then brings legs up against trunk.
Medical Professional: Assessed Tonic Reflex and neck range of motion.
Medical Professional: Assessed pulse.
Medical Professional: Assessed Rooting Reflex: Infant turns head in direction of stimulus and opens mouth.
Medical Professional: Infant responds with sucking motion. Tongue protrudes past lips.
Medical Professional: Assessed neurological stepping/walking reflex.
Medical Professional: Palpated abdomen.
Medical Professional: Anterior fontanelle palpated is diamond-shaped, soft, flat, approximately 2-3 cm in width and 3-4 cm in length. Posterior fontanelle is triangle shaped 0.5-1 cm in size, soft, and flat.
Medical Professional: Auscultated Upper Right Abdomen: Abdomen rounded, appropriate for age.
Medical Professional: Auscultated Upper Left Abdomen: Abdomen rounded, appropriate for age.
Medical Professional: Auscultated Lower Left Abdomen: Abdomen rounded, appropriate for age.
Medical Professional: Auscultated Lower Right Abdomen: Abdomen rounded, appropriate for age.
Medical Professional: Auscultated Top Right Chest: Apical pulse palpated reveals rate steady and regular intervals.
Medical Professional: Auscultated Top Left Chest: Apical pulse palpated reveals rate steady and regular intervals.
Medical Professional: Auscultated Upper Left Chest: Apical pulse palpated reveals rate steady and regular intervals.
Medical Professional: Auscultated Lower Left Chest: Apical pulse palpated reveals rate steady and regular intervals.
Medical Professional: Auscultated Lower Left Chest: Apical pulse palpated reveals rate steady and regular intervals.
Medical Professional: Auscultated Lower Left Chest: Apical pulse palpated reveals rate steady and regular intervals.
Medical Professional: Auscultated Upper Upper Right Chest.
Medical Professional: Auscultated Upper Upper Left Chest.
Medical Professional: Auscultated Upper Right Chest.
Medical Professional: Auscultated Upper Left Chest.
Medical Professional:
Auscultated Lower Left Chest.
Medical Professional: Auscultated Lower Right Chest.
Medical Professional: Auscultated Lower Right Back.
Medical Professional: Auscultated Lower Left Back.
Medical Professional: Auscultated Upper Left Back.
Medical Professional: Auscultated Upper Right Back.
Medical Professional: Auscultated Upper Upper Right Back.
Medical Professional: Auscultated Upper Upper Left Back.
TRANSCRIPT
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| Good morning. How are you? | Greet 02/18/22 7:58 PM EST |
|
| Hi. | ||
| you have a beautiful baby (No matching questions found.) | Question 02/18/22 7:58 PM EST |
|
| what brings you here? Zachary LaFontaine Infant Well Visit Shadow health | Question 02/18/22 7:59 PM EST |
|
| We’re here for Zachary’s wellness visit. It was hard to work it into our schedule, but I know it’s important. | ||
| I am glad you could make it. | Empathize 02/18/22 8:00 PM EST |
|
| I appreciate it. | ||
| How is Zachary doing? | Question 02/18/22 8:00 PM EST |
|
| Zachary is a very happy baby. He smiles quite a bit. It’s nice coming home from school or work to see him. | ||
| How old are you? (No matching questions found.) | Question 02/18/22 8:01 PM EST |
|
| where do you work? (No matching questions found.) Zachary LaFontaine Infant Well Visit Shadow health | Question 02/18/22 8:01 PM EST |
|
| who do you leave him with when you work? (No matching questions found.) | Question 02/18/22 8:02 PM EST |
|
| who do you leave him with when you work? (No matching questions found.) | Question 02/18/22 8:02 PM EST |
|
| it is important to interact with baby | Educate 02/18/22 8:03 PM EST |
|
| Ok, that sounds good. | ||
| How is he eating? | Question 02/18/22 8:03 PM EST |
|
| Zachary only gets breastmilk, no formula at all. | ||
| how many times a day does he eat? (Clarified to How often do you feed your son?.) | Question 02/18/22 8:03 PM EST |
|
| I try for 2-3 hours during the day and 3-4 at night. We don’t always manage it, though. (Clarified to how often I feed my son.) | ||
| how is he sleeping? | Question 02/18/22 8:04 PM EST |
|
| Zachary always has a hard time sleeping on nights I come home late, Tuesdays and Thursdays. It’s hard on me because I can barely get any sleep those nights, and I don’t get much as it is. I wake up early for class after taking care of Zachary all night. It’s a lot. | ||
| I understand it could be a lot, i am glad you are taking care of Zach | Empathize 02/18/22 8:06 PM EST |
|
| I appreciate that. | ||
| Zachary LaFontaine Infant Well Visit Shadow health | ||
| Zachary LaFontaine Infant Well Visit Shadow health | ||
| what are your goals for breastfeeding? | Question 02/18/22 8:31 PM EST |
|
| I want to only breastfeed Zachary. I know formula is an option, but that would be a last resort. I want to focus on giving my baby breast milk. | ||
| that is great. breast milk is the best for a baby | Educate 02/18/22 8:32 PM EST |
|
| I understand. | ||
| where your son sleep? (Clarified to Where does your son sleep?.) Zachary LaFontaine Infant Well Visit Shadow health | Question 02/18/22 8:32 PM EST |
|
| Zachary sleeps in a bassinet at night or sometimes in his cradleboard. He’s always swaddled and always on his back. I keep the bassinet empty and in my room, so I’m always nearby Zachary LaFontaine Infant Well Visit Shadow health. I’m really afraid of SIDS or anything like that, so I did a lot of reading on sleep safety. (Clarified to where my son sleeps.) | ||
| how is your son sleeping? | Question 02/18/22 8:33 PM EST |
|
| Zachary always has a hard time sleeping on nights I come home late, Tuesdays and Thursdays. It’s hard on me because I can barely get any sleep those nights, and I don’t get much as it is. I wake up early for class after taking care of Zachary all night. It’s a lot. | ||
| it is important sleep supervision for safety | Educate 02/18/22 8:34 PM EST |
|
| Good to know. | ||
| what do you know about developmental milestones? (No matching questions found.) | Question 02/18/22 8:34 PM EST |
|
| developmental milestones? (No matching questions found.) | Question 02/18/22 8:35 PM EST |
|
| milestones? (No matching questions found.) | Question 02/18/22 8:35 PM EST |
|
| milestones?any verbal language? (No matching questions found.) | Question 02/18/22 8:35 PM EST |
|
| any verbal language? (No matching questions found.) | Question 02/18/22 8:36 PM EST |
|
| does your son makes any sound? (Clarified to Does your son make gestures?.) | Question 02/18/22 8:36 PM EST |
|
| He squirms around a lot and smiles. [AUDIO COMING SOON] (Clarified to if my son makes gestures.) Zachary LaFontaine Infant Well Visit Shadow health | ||
| can your son make noise? | Question 02/18/22 8:37 PM EST |
|
| He coos and burbles. It’s pretty cute. | ||
| are you reading books? (No matching questions found.) | Question 02/18/22 8:38 PM EST |
|
| are you learning about kids? (No matching questions found.) | Question 02/18/22 8:38 PM EST |
|
| are you learning about your son? (No matching questions found.) | Question 02/18/22 8:38 PM EST |
|
| does your son follow sounds? (Clarified to Does your son track you with his eyes?.) | Question 02/18/22 8:39 PM EST |
|
| He does, yes. He also loves staring at strangers. He seems curious about everything. (Clarified to if my son follows me with his eyes.) | ||
| does your son follows the sound of your voice? | Question 02/18/22 8:39 PM EST |
|
| Zachary will look at me if I talk to him. Sometimes he’ll stare at me or make a little coo. [AUDIO COMING SOON] | ||
| are you depressed? | Question 02/18/22 8:40 PM EST |
|
| Well . . . I don’t know? I don’t think I’m technically depressed, but I’ve just been so busy and tired that I barely have time to reflect on myself like that. I feel overwhelmed. I don’t know how I am going to handle everything and raise Zachary. But I’ll figure it out. I have to. [AUDIO COMING SOON] | ||
| post partum depression is a frequent finding, please let us know if anything we can help with | Educate 02/18/22 8:41 PM EST |
|
| Alright, thanks. | ||
| Inspected head circumference growth chart | Exam Action 02/18/22 8:41 PM EST |
|
| Inspected weight and length growth chart | Exam Action 02/18/22 8:51 PM EST |
|
| Inspected head circumference growth chart | Exam Action 02/18/22 8:57 PM EST |
|
| Inspected nose | Exam Action 02/18/22 8:58 PM EST |
|
| Inspected ears | Exam Action 02/18/22 8:59 PM EST |
|
| Frenulum attached middle of mouth floor. Appropriate length and movements. Appears thin. Palate meets at the midline completely. Tongue appears smooth and uvula located at midline. Zachary LaFontaine Infant Well Visit Shadow health | Exam Action 02/18/22 8:59 PM EST |
|
| Inspected ears | Exam Action 02/18/22 9:00 PM EST |
|
| Frenulum attached middle of mouth floor. Appropriate length and movements. Appears thin. Palate meets at the midline completely. Tongue appears smooth and uvula located at midline. | Exam Action 02/18/22 9:00 PM EST |
|
| Inspected skin | Exam Action 02/18/22 9:00 PM EST |
|
| Inspected skin: diaper area | Exam Action 02/18/22 9:01 PM EST |
|
| Inspected genitalia | Exam Action 02/18/22 9:01 PM EST |
|
| Assessed Musculoskeletal Barlow and Ortolani | Exam Action 02/18/22 9:02 PM EST |
|
| Assessed eyes: pupils | Exam Action 02/18/22 9:04 PM EST |
|
| Assessed red reflex | Exam Action 02/18/22 9:05 PM EST |
|
| Assessed Eye Tracking | Exam Action 02/18/22 9:05 PM EST |
|
| Assessed extremities | Exam Action 02/18/22 9:05 PM EST |
|
| Assessed grasp: Able to lift shoulders off table with expected head lag. | Exam Action 02/18/22 9:06 PM EST |
|
| Assessed Moro Reflex: Infant briskly abducts arms and legs symmetrically, then brings legs up against trunk. Zachary LaFontaine Infant Well Visit Shadow health | Exam Action 02/18/22 9:06 PM EST |
|
| Assessed Moro Reflex: Infant briskly abducts arms and legs symmetrically, then brings legs up against trunk. | Exam Action 02/18/22 9:06 PM EST |
|
| Assessed Tonic Reflex and neck range of motion. | Exam Action 02/18/22 9:06 PM EST |
|
| Assessed pulse | Exam Action 02/18/22 9:06 PM EST |
|
| Assessed Rooting Reflex: Infant turns head in direction of stimulus and opens mouth. | Exam Action 02/18/22 9:07 PM EST |
|
| Infant response with sucking motion. Tongue protrudes past lips. | Exam Action 02/18/22 9:07 PM EST |
|
| Assessed neurological stepping/walking reflex | Exam Action 02/18/22 9:07 PM EST |
|
| Palpated abdomen | Exam Action 02/18/22 9:08 PM EST |
|
| Anterior fontanelle palpated is diamond-shaped, soft, flat, approximately 2-3 cm in width and 3-4 cm in length. Posterior fontanelle is triangle shaped 0.5-1 cm in size, soft, and flat. | Exam Action 02/18/22 9:08 PM EST |
|
| Auscultated Upper Right Abdomen: Abdomen rounded, appropriate for age. | Exam Action 02/18/22 9:09 PM EST |
|
| Auscultated Upper Left Abdomen: Abdomen rounded, appropriate for age. | Exam Action 02/18/22 9:09 PM EST |
|
| Auscultated Lower Left Abdomen: Abdomen rounded, appropriate for age. Zachary LaFontaine Infant Well Visit Shadow health | Exam Action 02/18/22 9:09 PM EST |
|
| Auscultated Lower Right Abdomen: Abdomen rounded, appropriate for age. | Exam Action 02/18/22 9:09 PM EST |
|
| Auscultated Top Right Chest: Apical pulse palpated reveals rate steady and regular intervals. | Exam Action 02/18/22 9:10 PM EST |
|
| Auscultated Top Left Chest: Apical pulse palpated reveals rate steady and regular intervals. | Exam Action 02/18/22 9:10 PM EST |
|
| Auscultated Upper Left Chest: Apical pulse palpated reveals rate steady and regular intervals. | Exam Action 02/18/22 9:10 PM EST |
|
| Auscultated Lower Left Chest: Apical pulse palpated reveals rate steady and regular intervals. Zachary LaFontaine Infant Well Visit Shadow health | Exam Action 02/18/22 9:10 PM EST |
|
| Auscultated Lower Left Chest: Apical pulse palpated reveals rate steady and regular intervals. | Exam Action 02/18/22 9:10 PM EST |
|
| Auscultated Lower Left Chest: Apical pulse palpated reveals rate steady and regular intervals. | Exam Action 02/18/22 9:10 PM EST |
|
| Auscultated Upper Upper Right Chest | Exam Action 02/18/22 9:10 PM EST |
|
| Auscultated Upper Upper Left Chest | Exam Action 02/18/22 9:10 PM EST |
|
| Auscultated Upper Right Chest | Exam Action 02/18/22 9:10 PM EST |
|
| Auscultated Upper Left Chest | Exam Action 02/18/22 9:10 PM EST |
|
| Auscultated Lower Left Chest | Exam Action 02/18/22 9:10 PM EST |
|
| Auscultated Lower Right Chest | Exam Action 02/18/22 9:10 PM EST |
|
| Auscultated Lower Right Back | Exam Action 02/18/22 9:11 PM EST |
|
| Auscultated Lower Left Back | Exam Action 02/18/22 9:11 PM EST |
|
| Auscultated Upper Left Back | Exam Action 02/18/22 9:11 PM EST |
|
| Auscultated Upper Right Back | Exam Action 02/18/22 9:11 PM EST |
|
| Auscultated Upper Upper Right Back | Exam Action 02/18/22 9:11 PM EST |
|
| Auscultated Upper Upper Left Back Zachary LaFontaine Infant Well Visit Shadow health | Exam Action 02/18/22 9:11 PM EST |