Zachary LaFontaine Shadow health Treatment Plan
Diagnosis:
Encounter for routine child health examination with abnormal findings.
Evidence:
Ms. LaFontaine reports that the reason for the visit is related to feeding difficulties and infant weight gain issues.
The pediatric diagnosis indicates that Zachary’s growth is not aligning with the developmental milestones expected for his age.
This encounter is for a routine wellness visit for infants, but concerns about infant nutrition and feeding have prompted additional attention.
Learner Rationale:
The visit was initiated due to Zachary’s abnormal growth pattern and signs of feeding difficulties in infants. As a pediatric care provider, it is important to address these issues promptly to prevent further developmental delays. A thorough child health examination is essential to identify and document abnormal findings accurately, ensuring Zachary receives appropriate care.
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Score: 3 out of 3
Additional Diagnosis: Feeding Difficulty
Diagnosis:
Feeding difficulty or infant feeding difficulties.
Evidence:
- Breasts are not always empty after feeding (suggesting ineffective latch or insufficient milk supply).
- Drop in weight percentile for age (indicating possible infant weight gain issues and potential malnutrition).
- Feeding sessions of insufficient length (potentially linked to inadequate feeding duration, which impacts overall intake).
- Less frequent than normal elimination (sign of possible dehydration or insufficient feeding).
- Mother does not perceive enough time to feed (indicating potential feeding challenges and inadequate nutrition).
Learner Rationale:
Zachary’s feeding difficulties have resulted in reduced weight gain and abnormal feeding patterns. These signs are often associated with pediatric care treatment plans for feeding difficulties. Breastfeeding support and lactation consultation are critical to improving feeding efficiency and ensuring Zachary receives proper nutrition for healthy growth. 
Score: 6 out of 6
Plan of Care
Pharmacological Intervention
Selected: No
Recommended:
Zachary may be vitamin D deficient, which is common in breastfed infants as breast milk typically lacks sufficient levels of vitamin D. Vitamin D supplementation for infants is essential for supporting bone health and overall development. As a pediatric treatment plan, vitamin D supplementation is crucial to address this deficiency, especially in cases of breastfeeding challenges.
Learner Rationale:
Vitamin D is necessary for child health examination and preventing issues like rickets, which can occur due to vitamin D deficiency. This supplementation is essential in pediatric care, particularly in breastfeeding support scenarios where the baby is not receiving enough vitamin D from breast milk alone.
Score: 1 out of 1
Non-Pharmacological Intervention
Selected: Yes
Recommended:
Encourage Daanis to create a structured feeding schedule and acquire a breast pump to ensure Zachary’s nutritional needs are fully met. Structured feedings can help in addressing infant feeding difficulties, especially when the mother feels she doesn’t have enough time to properly breastfeed. A more organized approach, including pumping, will support Zachary’s infant nutrition and help him reach appropriate developmental milestones in infants.
Learner Rationale:
A non-pharmacological intervention in pediatric care like encouraging a feeding schedule and using a breast pump can significantly improve infant nutrition counseling and help manage breastfeeding challenges. These measures will help resolve feeding difficulties in infants by ensuring adequate milk intake and promoting appropriate weight gain.
Score: 1 out of 1
Educate Guardian
Selected: Yes
Recommended: 
Providing education to Daanis about pediatric care is essential. Education on developmental milestones in infants, feeding techniques, and how to recognize and address feeding difficulties will empower Daanis to better meet Zachary’s needs. Teaching Daanis about non-pharmacological interventions and infant nutrition counseling can help her confidently address feeding difficulties at home, improving adherence to the treatment plan.
Learner Rationale:
Education plays a key role in pediatric care treatment plans. By educating Daanis on feeding strategies and infant nutrition, she can provide the best care for Zachary, ensuring he meets his developmental milestones and receives optimal nutrition.
Score: 1 out of 1
Preventive Screening and Vaccines
Selected: Yes
Recommended:
At two months, Zachary is due for a series of pediatric vaccines:
- Hepatitis B (HepB)
- Rotavirus (RV)
- Diphtheria, Tetanus, and Acellular Pertussis (DTaP)
- Pneumococcal conjugate (PCV13)
- Inactivated poliovirus (IPV)
- Haemophilus influenzae (HiB)
These vaccines are crucial to protecting Zachary’s health as part of his routine wellness visits for infants. Discuss the importance of these vaccines with Daanis and administer them with her consent.
Learner Rationale:
As part of routine pediatric care, immunizations ensure that infants are protected against serious diseases. A pediatric vaccines schedule must be followed to promote child health examination and prevent complications.
Score: 1 out of 1
Diagnostic Testing: Labs and Imaging
Selected: No
Recommended:
No diagnostic tests are required at this time, as the primary diagnosis is clear based on the clinical examination and the evidence of feeding difficulties and infant nutrition issues. 
Learner Rationale:
As the pediatric diagnosis is clear from Zachary’s clinical presentation, no further diagnostic tests are needed. The interventions recommended are sufficient to address his current concerns.
Score: 1 out of 1
Referral of Care
Selected: Yes
Recommended:
Referral to a lactation consultant is recommended to address Zachary’s breastfeeding challenges and improve Daanis’s feeding practices. A lactation consultant will help Daanis integrate a more effective feeding plan with her busy schedule, ensuring Zachary’s nutritional needs are met. This will enhance the quality of care provided and assist in resolving feeding difficulties.
Learner Rationale:
A lactation consultation will help improve breastfeeding technique and increase milk supply, addressing Zachary’s feeding difficulties. This is an essential step in supporting both mother and infant for optimal pediatric care outcomes.
Score: 1 out of 1
Continued Care and Follow-Up
Selected: Yes
Recommended:
A follow-up appointment should be scheduled to monitor Zachary’s developmental milestones and ensure that the interventions are effective in resolving feeding difficulties and improving infant weight gain. Early intervention will help ensure that Zachary remains on track for healthy development.
Learner Rationale:
Routine wellness visits for infants are essential to track progress. By scheduling a follow-up appointment, you can ensure the treatment plan for feeding difficulties is successful and monitor Zachary’s growth. This will also allow adjustments to be made if necessary, ensuring optimal pediatric care.
Score: 1 out of 1
Summary Treatment Plan for Zachary LaFontaine
- Primary Diagnosis: Encounter for routine child health examination with abnormal findings related to infant feeding difficulties and pediatric care treatment plan.
- Additional Diagnosis: Feeding difficulty due to breastfeeding challenges, leading to infant weight gain issues and inadequate nutrition.
- Pharmacological Intervention: Vitamin D supplementation for infants due to potential deficiency.
- Non-Pharmacological Intervention: Create a structured feeding schedule and use a breast pump to support Zachary’s nutrition and growth.
- Education for Guardian: Educate Daanis on infant nutrition counseling, feeding strategies, and how to support developmental milestones in infants.
- Preventive Care: Administer the pediatric vaccines schedule as Zachary is due for vaccinations.
- Referral: Referral to a lactation consultant for breastfeeding support and resolving feeding difficulties.
- Follow-Up: Schedule a follow-up appointment to track Zachary’s progress in meeting developmental milestones and improving weight gain.
Zachary LaFontaine Shadow health Treatment Plan
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 Zachary LaFontaine Shadow health Treatment Plan.
| Learner Selection | Model Documentation |
|
Diagnosis: Encounter for routine child health examination with abnormal findings Identified as xxx Evidences: Ms. LaFontaine reports that the reason for the visit is a xx Learner Rationale: Dannis reported that he brought her xxx Score: 3 out of 3 |
Diagnosis: Encounter for routine child health examination with abnormal findings Primary: xxx Evidences: Ms. LaFontaine reports that the reason for the visit is a xxx Model Rationale: The xxis the reason for the xx Because Ms. LaFontaine has indicated she has brought Zachary in for his wxxx, the correct xxxis “Encounter for routine child health examination with abnormal findings Zachary LaFontaine Shadow health Treatment Plan.” 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: xxx 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 Learner Rationale: Zachary’s reduced weight gain suggests he has feeding problems Score: 6 out of 6 |
Diagnosis: xxx 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. Zachary LaFontaine Shadow health Treatment Plan 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. |
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: xx Learner Rationale: Vxxx Score: 1 out of 1 |
Recommended: xxx
Zachary may be xxx, which is critical for infant xxx. xx is common in children who are breastfed, as breast milk contains no xx. You will recommend an xxxxto Daanis for Zachary to take Zachary LaFontaine Shadow health Treatment Plan. |
|
Non-Pharmacological Intervention
Selected:xx Learner Rationale: Dannis should be dencouraged to create a feeding schedule Score: 1 out of 1 |
Recommended: xxx
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: xxx Learner Rationale: Pediatric care necessitates education Score: 1 out of 1 |
Recommended: xxx
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: xx Learner Rationale: The patient is due for several vaccines Score: 1 out of 1 |
Recommended: xx
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) Zachary LaFontaine Shadow health Treatment Plan. 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: No diagnostic tests are required Score: 1 out of 1 |
Recommended: No
As the patient’s diagnosis is evident, no further diagnostic testing is needed. |
|
Referral of Care
Selected: xx Learner Rationale: Dannis should consult with a lactation specialist Score: 1 out of 1 |
Recommended: xxA 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: A follow p appointment should be scheduled to check if the interventions are working Score: 1 out of 1 |
Recommended: YesBecause 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 Zachary LaFontaine Shadow health Treatment Plan. |
Zachary LaFontaine’s Treatment Plan
Problem Selection
– Primary Diagnosis:
– Diagnosis: Encounter for routine child health examination with abnormal findings.
– Evidences: Ms. LaFontaine reports that the reason for the visit is related to specific issues.
– Additional Diagnosis:
– 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, and mother does not perceive enough time to feed.
Plan of Care
– Pharmacological Intervention:
– Selected: No
– Recommended: Zachary may be vitamin D deficient, which is critical for infant development, especially in breastfed infants. You will recommend vitamin D supplementation for Zachary.
– Non-Pharmacological Intervention:
– Selected: Yes
– Recommended: You will encourage Daanis to create a structured feeding schedule and acquire a breast pump. This will help meet Zachary’s nutritional needs and support Daanis’s well-being.
– Educate Guardian:
– Selected: Yes
– Recommended: Providing education to parents is crucial in pediatric care. Clearly communicating the care needed for their children improves adherence and outcomes.
– Preventive Screening and Intervention:
– Selected: Yes
– Recommended: At two months, Zachary is due for several vaccines, including Hepatitis B, Rotavirus, Diphtheria, Tetanus, Acellular pertussis, Pneumococcal conjugate, Inactivated poliovirus, and Haemophilus influenzae. Discuss the need for these vaccines and administer them with consent.
– Diagnostic Testing: Labs and Imaging:
– Selected: No
– Recommended: No further diagnostic tests are needed as the diagnosis is clear.
– Referral of Care:
– Selected: Yes
– Recommended: Daanis should consult with a lactation specialist to improve her feeding practices and integrate her busy schedule with Zachary’s needs.
– Continued Care and Follow-up:
– Selected: Yes
– Recommended: Schedule a follow-up appointment to ensure the interventions are working and to monitor Zachary’s development and weight gain. Waiting for the four-month wellness visit might be too late given his developmental delay.
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