Shadow Health Assignments
Zachary LaFontaine Treatment Plan Shadow health
Primary Diagnosis
Review the answers for the Problem Selection tasks. You get a point for each correct diagnosis and evidence linked to it. If there are multiple correct diagnoses, you also get a point for selecting the primary diagnosis.
Diagnosis: Regular infant health check with abnormal findings
Identified as primary
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Evidences:
Ms. LaFontaine reports the visit is for a routine well-child exam
Score: 2 out of 3
Diagnosis: Regular infant health check with abnormal findings
Primary: Yes
Evidences:
Ms. LaFontaine reports the visit is for a routine well-child exam
Model Explanation:
The primary diagnosis is the reason for the patient’s visit. Since Ms. LaFontaine brought Zachary for his well-child exam, the main diagnosis is “Regular infant health check with abnormal findings.” It’s important to code the reason for Zachary’s visit correctly for insurance coverage.
Additional Diagnosis
Diagnosis: Feeding Difficulties
Evidences:
Breasts not always empty after feeding
Falling asleep while breastfeeding
Feeding sessions too short
Mother feels rushed during feeding
Mother’s calorie intake insufficient
Learner Explanation:
I found a normally developing infant
Score: 4 out of 6
Diagnosis: Feeding Difficulties
Evidences:
Breasts not always empty after feeding
Drop in weight percentile for age
Feeding sessions too short
Less frequent eliminations than normal
Mother feels rushed during feeding
Model Explanation:
A delay in appropriate weight gain and less frequent eliminations indicate feeding, nutrition, or digestion issues. Ms. LaFontaine’s breasts not emptying after feeding suggests latching issues or insufficient milk expression. However, she also reports not having enough time to feed and short feeding sessions. This makes “Feeding Difficulties” the correct additional diagnosis.
Plan of Care
Pharmacological Intervention
Selected: No
Learner Explanation:
Not needed for the baby. But the mother might need supplements like multivitamins.
Score: 0 out of 1
Recommended: Yes
Zachary might lack Vitamin D essential for bone and tooth growth. As breast milk lacks Vitamin D, you’ll suggest an OTC Vitamin D supplement for Zachary.
Non-Pharmacological Intervention
Selected: Yes
Learner Explanation:
Infant nutrition and breastfeeding education.
Score: 1 out of 1
Recommended: Yes
You’ll discuss getting a breast pump and creating an effective feeding schedule. A structured schedule and breast pumping will meet Zachary’s needs and maintain the mother’s well-being.
Educate Guardian
Selected: Yes
Learner Explanation:
Same as above.
Score: 1 out of 1
Recommended: Yes
Educating guardians is vital in pediatrics. Clear communication improves adherence and outcomes.
Preventive Screening and Intervention
Selected: No
Learner Explanation:
Not necessary.
Score: 0 out of 1
Recommended: Yes
At 2 months, Zachary needs vaccines: Hepatitis B (HepB), Rotavirus (RV), DTaP, PCV13, IPV, HiB. You’ll explain these and administer with consent.
Diagnostic Testing: Labs and Imaging
Selected: No
Learner Explanation:
Not necessary.
Score: 1 out of 1
Recommended: No
No further testing is required as the diagnosis is evident.
Referral of Care
Selected: Yes
Learner Explanation:
Breastfeeding education, mother’s health, caloric intake, supplements or vitamins use.
Score: 1 out of 1
Recommended: Yes
A lactation specialist will help improve feeding practices and integrate the mother’s schedule with Zachary’s needs. Refer to a specialist within Indian Health Services.
Continued Care and Follow-up
Selected: Yes
Learner Explanation:
In 2 months or sooner if necessary.
Score: 1 out of 1
Recommended: Yes
Zachary’s developmental lag makes waiting for his 4-month visit inappropriate. Schedule a follow-up to ensure interventions work and he gains weight appropriately.
Treatment Plan: 11 of 16 (68.75%)
Problem Selection
6 out of 9
Primary Diagnosis
Review your answers for the Problem Selection activities. You receive one point for each correct diagnosis, and one point for each correct evidence linked to a correct diagnosis. If there are multiple correct diagnoses, you will also receive a point for correctly selecting which diagnosis is the primary diagnosis.
| Learner Selection | Model Documentation |
|
Diagnosis: Encounter for routine child health examination with abnormal findings Identified as primary Evidences: Ms. LaFontaine reports that the reason for the visit is a well-child exam Learner Rationale: nothing Score: 2 out of 3 |
Diagnosis: Encounter for routine child health examination with abnormal findings Primary: Yes Evidences: Ms. LaFontaine reports that the reason for the visit is a well-child exam Model Rationale: The primary diagnosis is the reason for the patient’s visit. Because Ms. LaFontaine has indicated she has brought Zachary in for his well-child exam, the correct primary diagnosis is “Encounter for routine child health examination with abnormal findings.” As a primary care provider, it is critical to properly code the reason for Zachary’s visit so it can be covered by insurance. |
Additional Diagnosis
| Learner Selection | Model Documentation |
|
Diagnosis: Feeding Difficulty Evidences: Breasts are not always empty after feeding Falling asleep while breastfeeding Feeding sessions of insufficient length Mother does not perceive enough time to feed Mother does not consume enough calories Learner Rationale: I really found a normal developed infant Score: 4 out of 6 |
Diagnosis: Feeding Difficulty Evidences: Breasts are not always empty after feeding Drop in weight percentile for age Feeding sessions of insufficient length Less frequent than normal elimination Mother does not perceive enough time to feed Model Rationale: A delay or reduction in developmentally appropriate weight gain indicates that Zachary has a problem related to feeding, nutrition, or digestion, as does his somewhat infrequent eliminations. Daanis reports that her breasts do not always feel empty after feedings, which could be an indication that Zachary is experiencing mechanical problems with latching or that Daanis cannot express breast milk. However, Daanis also reports that she does not feel like she has enough time to feed Zachary, and describes feeding sessions that are shorter than recommended. This leads to “Feeding difficulty” being the correct additional diagnosis. Kerzner B et al. (2015). A practical approach to classifying and managing feeding difficulties. Pediatrics, 135(2): 344. |
Plan of Care
5 out of 7
Review your answers for the Plan of Care activity. You must select “Yes” or “No” for each of the seven care actions. You will receive one point for determining the correct answer for each care action.
| Learner Selection | Model Documentation |
|
Pharmacological Intervention
Selected: No Learner Rationale: No for the infant. In the other hand, the mother will need suplements such as multivitamis Score: 0 out of 1 |
Recommended: Yes
Zachary may be deficient in Vitamin D, which is critical for infant bone and tooth development. Vitamin D deficiency is common in children who are breastfed, as breast milk contains no Vitamin D. You will recommend an OTC Vitamin D supplement to Daanis for Zachary to take. |
|
Non-Pharmacological Intervention
Selected: Yes Learner Rationale: Infant nutrition, and breast feeding education. Score: 1 out of 1 |
Recommended: Yes
You will talk to Daanis about acquiring a breast pump and planning an effective feeding schedule. A more structured feeding schedule and the use of a breast pump will allow Daanis to fully meet Zachary’s nutritional needs while also maintaining her own well being. |
|
Educate Guardian
Selected: Yes Learner Rationale: as above Score: 1 out of 1 |
Recommended: Yes
Providing education to patients’ guardians is a key component of pediatric practice. Clearly communicating to guardians what care their children need and why improves adherence and outcomes. |
|
Preventive Screening and Intervention
Selected: No Learner Rationale: not need it Score: 0 out of 1 |
Recommended: Yes
At two months, Zachary is due for several vaccines: Hepatitis B (HepB), Rotavirus (RV), Diphtheria, Tetanus and Acellular pertussis (DTaP), Pneumococcal conjugate (PCV13), Inactivated poliovirus (IPV), and Haemophilus influenzae (HiB). You will talk to Daanis about the need for these vaccines and administer them with her consent. |
|
Diagnostic Testing: Labs and Imaging
Selected: No Learner Rationale: not need it Score: 1 out of 1 |
Recommended: No
As the patient’s diagnosis is evident, no further diagnostic testing is needed. |
|
Referral of Care
Selected: Yes Learner Rationale: Breastfeeding education. Mother health, caloric intake, supplements or vitamis use. Score: 1 out of 1 |
Recommended: Yes
A lactation specialist will allow Daanis to improve her feeding practices and integrate her challenging schedule with Zachary’s nutritional and emotional needs. You will refer Daanis to a lactation specialist that is in network with Indian Health Services. |
|
Continued Care and Follow-up
Selected: Yes Learner Rationale: in 2 months of before if needed. Score: 1 out of 1 |
Recommended: Yes Dont wait until the last minute.Provide your requirements and let our native nursing writers deliver your assignments ASAP. Because Zachary is lagging developmentally, it would not be appropriate to wait for his four-month wellness visit to see if the interventions you have selected are working. You will schedule a follow-up appointment with Daanis to make sure that the interventions have resolved Zachary’s feeding problems and that he is gaining weight in a developmentally appropriate way. |