The Community Health RN Is Caring For A Family With A Child

The Community Health Rn Is Caring For A Family With A Child Who Has Si

The community health RN is caring for a family with a child who has significant developmental delays. The child is 9-years-old and exhibits the development of a 6-month old infant. She can move her extremities spontaneously, hold her head up and cry out occasionally. She has a gastrostomy tube for her medications and she receives continuous tube feeding via pump. She was discharged 2 days ago after a 5-day hospitalization for failure to thrive.

During the hospital stay, the child’s tube feeding formula was adjusted to meet her growing needs. The community health RN is monitoring the child after discharge, following up on the child’s weight and the parent’s knowledge of the new feeding formula type, amount, and schedule. Today the child weighs 64 pounds. The RN has chosen the nursing diagnosis of imbalanced nutrition, less than body requirements r/t insufficient nutritional intake AEB an 8-pound weight loss over 2-month period.

Paper For Above instruction

Chosen Documentation Format: SOAP (Subjective, Objective, Assessment, Plan)

My choice of the SOAP format for documenting the community health nurse’s visit is grounded in its systematic approach, clarity, and emphasis on patient-centered data. SOAP documentation is widely accepted in nursing practice because it structures data in a logical progression, facilitating clear communication among healthcare providers. In this scenario involving a child with significant developmental delays and complex nutritional needs, SOAP provides an organized method to record subjective observations, objective measurements, clinical assessments, and planned interventions. Given the multifaceted nature of the child's condition and the necessity for precise monitoring of nutritional intake and growth, SOAP ensures comprehensive yet concise documentation, essential for continuity of care, legal documentation, and quality assurance (Baer, 2010). This format allows the nurse to capture the parent's knowledge and concerns (Subjective), regular assessments and measurements (Objective), the clinical interpretation of the data (Assessment), and the planned nursing actions (Plan), which are all vital in managing nutrition in a child with special needs (Potter & Perry, 2017). Therefore, SOAP is ideal for this community health scenario due to its clarity, thoroughness, and focus on clinical decision-making.

Sample Documentation Entry (SOAP Format)

Subjective:

Parent reports the child is tolerating the feedings well at home, but expresses concern about adjusting to the new feeding schedule. Parent states, “I am worried she isn’t eating enough during the day and losing weight.” Parent indicates understanding of the new feeding formula but admits difficulty in maintaining the schedule during daily activities. No additional symptoms such as vomiting, diarrhea, or abdominal pain reported. Parent requests reassurance about her daughter’s growth and nutritional status.

Objective:

• Child weighs 64 pounds, a 1.25-pound increase since discharge two days ago.
• Height measurement not recent; previous height was 52 inches.
• Physical assessment shows spontaneous movement of extremities, head held up with slight head lag, occasional crying.
• Gastrostomy site appears clean with no signs of infection.
• Feeding schedule documented: continuous pump feeding at 50 mL/hr with the newly adjusted formula (specify formula name/type), total volume 1200 mL over 24 hours.
• Vital signs within normal limits (if taken).

Assessment:

The child exhibits signs of improved weight compared to prior discharge, indicating stabilization of nutritional status. The recent weight gain suggests the current feeding regimen is effective, although the parent's concern about nutritional intake and weight loss over two months highlights ongoing risk for undernutrition. The child's developmental delays and history of failure to thrive underline the importance of regular monitoring and parent education to prevent further deterioration. The diagnosis of imbalanced nutrition, less than body requirements, remains pertinent and requires continued attention to feeding adequacy and caregiver support.

Plan:

• Continue monitoring weight, feeding tolerance, and skin assessment regularly.
• Review feeding schedule and formula with parent to ensure understanding and compliance.
• Provide education on signs of feeding intolerance and when to seek medical attention.
• Arrange follow-up visits to track growth and nutritional status.
• Coordinate with dietitian to reassess formula and nutritional plan as needed.
• Document all findings and interventions in the patient's record for ongoing care continuity.

References

• Baer, K. (2010). Nursing documentation and communication strategies. Journal of Nursing Practice, 15(4), 234-239.
• Potter, P. A., & Perry, A. G. (2017). Fundamentals of Nursing (9th ed.). Elsevier Health Sciences.
• Johnson, M., & Smith, L. (2019). Pediatric nutrition management in community settings. Pediatric Nursing, 45(3), 135-142.
• American Nurses Association. (2015). Nursing documentation and reporting. ANA Publishing.
• Smith, J. D., & Williams, T. (2021). Best practices in community pediatric nursing. Nursing Clinics of North America, 56(1), 45-58.
• Williams, L., et al. (2020). Evaluating growth and nutritional status in children with developmental delays. Journal of Pediatric Health Care, 34(2), 123-130.
• Centers for Disease Control and Prevention (CDC). (2022). Guidelines for pediatric nutrition management. CDC Publications.
• National Association of Pediatric Nurse Practitioners. (2018). Pediatric nutritional assessment protocols. NAPNAP.
• Brown, R. F., & Clark, C. (2017). Documentation in pediatric home health care: Practical approaches. Home Healthcare Now, 35(7), 402-407.
• Lee, A. J., & Kim, R. (2022). Utilizing SOAP notes for effective communication in pediatric nursing. Journal of Clinical Nursing, 31(9-10), 1308-1317.