Chamberlain College of Nursing - NR 602 NRLataille.Week5.SOAP.

CC- Behavioral difficulties, poor performance in school HPI- Mother reports since moving back in with her parents that Jo has started throwing tantrums and refusing to obey. The mother reports that she has always been active with frequent changes in activity and difficulty in staying seated or minding her own business. However, since the move and starting kindergarten, others have commented on difficulties in behavior, including Kayla’s own parents and Jo’s teacher. She is doing poorly in school and has had many behavioral issues there and been sent to the principal’s office on three occasions. No change in diet; no fever; no communicable disease symptoms; Current medications- children’s chewable multivitamin with iron daily Allergies- NKA PMH: Full-tern gestation delivered c-section, birth weight= 7lb 4oz, no complications during pregnancy, mother smoked 1 PPD throughout pregnancy, no hospitalizations Social History: Currently lives with her mother and maternal grandparents for the last 8 weeks. Their father is involved but lives 2 hours away in the state capital where he works. Jo has started kindergarten this fall in the community’s elementary school. She eats three meals and two snacks a day. There is a great deal of juice, soda, and processed or quick foods given in the house. She brushes her teeth twice a day, ride in car seats in the car, and play vigorously both indoors and outdoors at home. Sleep includes going to bed around 10:30 p.m. at night and being awakened at 6 a.m. for school. She continues to be difficult to get in bed with frequently getting up in the first hour of bedtime. Family History: Maternal and paternal parents are smokers. The mother has been one since age 22 at one pack-per-day until 18 months ago. The father continues to smoke. There were no diseases reported in either parent. Mother has a history with gestational diabetes and preeclampsia. ROS: Constitutional- Denies fever or communicable disease symptoms HEENT- Not reported Skin- Not reported Cardiovascular- Not reported