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Pediatric Evaluation and Plan of Care

Student`s Name

Institution

Course

Instructor name

Date
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This pediatric assessment and care plan is focused on Leo, an 8-month-old

infant displaying delayed gross and fine motor skills, limited reactivity to stimuli, and mild

regulation problems. The developmental trajectory of Leo has been meticulously observed, and

this complete evaluation seeks to formulate a customized intervention strategy to facilitate his

advancement and development. By implementing a collaborative strategy that incorporates

regular physical therapy sessions, a structured Home Exercise Program (HEP), and a supportive

home setting, the objective is to enhance Leo's motor skill development, sensory stimulation, and

general interaction with the external environment. This strategy aims to enhance the

developmental milestones of Leo by incorporating parental involvement and support, thereby

equipping his caregivers with the essential tools and guidance.

The patient's name is Leo.

The date provided is September 29, 2023.

Date of Birth: January 24, 2023 Current Age: 8 months and 5 days
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I. DATA COLLECTION

A. Medical History and Background:

The prenatal history of the individual under consideration does not present any notable or

significant findings.

The gestational age of the pregnancy is currently 38 weeks.

The birth weight of the individual in question was recorded as 3.2 kilograms.

The APGAR score of the newborn was recorded as 9 at 1 minute after birth and remained at 9 at

5 minutes after birth.

There were no perinatal problems observed.

The duration of postnatal hospitalization is typically four days.

There were no instances of re-hospitalizations observed.

There have been no surgical procedures performed.

Age at the time of diagnosis: Not applicable.

The current medical practitioners and experts include Dr. Smith, who specializes in pediatrics.

There are no other therapies or interventions that have been identified.

The individual is not currently taking any drugs.

B. Overview of Function:

The individual exhibits delayed development in both fine and gross motor skills, as seen by

difficulties in grasping objects and inadequate head control.

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Language: Prelinguistic vocalizations

Feeding: The process of moving from exclusive breastfeeding to the introduction of solid foods.

Cognition: Restricted Reactivity to Stimuli

C. Family and Environmental Characteristics:

The topic of discussion is to the daily routines that individuals engage in on a regular basis.

Routine pediatric examinations, without the presence of childcare services.

The topic of discussion revolves around participation and the various barriers associated with it.

The individual exhibits reduced levels of vigilance, limited engagement in social relationships,

and encounters some challenges related to the process of nourishment.

The topic of discussion pertains to familial matters, including concerns, expectations, and goals.

Enhanced motor abilities, heightened environmental engagement, and heightened state of

vigilance.

II. EXAMINATION

Posture and Movement Behaviors during Functional Tasks:

In the domain of gross motor skills, the prone position is of particular interest. The individual

exhibits a restricted capacity to raise their head, while also experiencing challenges in rolling

over while in a supine position.

The act of sitting necessitates the provision of support.

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The task of standing has not been attempted at this time.

The utilization of transitions has not been made in the text thus far.

The act of transferring has not been undertaken at this time.

Lack of mobility: Exhibits substantial challenges in crawling

The individual exhibits restricted manual dexterity, characterized by a limited ability to grip

objects, as well as suboptimal coordination between their hand movements and visual perception.

Activities of Daily Living (ADLs) encompass the fundamental tasks of feeding and dressing that

necessitate external aid.

The individual exhibits an intact sucking reflex in the oral motor domain, although encounters

difficulties while consuming solid foods.

The individual has restricted responsiveness to auditory stimuli and displays little vocalization in

the form of babbling.

Individual System Impairments:

The neuromuscular system exhibits characteristics such as suboptimal muscle grading, restricted

synergistic movements, and delayed reciprocal inhibition.

Musculoskeletal: The range of motion is within normal limits throughout, with the exception of

restricted neck rotation.

The individual has some physical limitations, including limited head control, a weak grasp, and

poor trunk control.

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Endurance: Demonstrates a rapid onset of fatigue during motor tasks.

No skeletal anomalies were observed.

The cardiovascular system appears to be within the expected range and does not present any

notable issues.

No anomalies were identified in respiration.

The integumentary system exhibits no evidence of surgical scars or abnormalities.

Gastrointestinal: Infrequent occurrence of reflux, absence of any other observed issues.

Regulatory concerns pertaining to state regulation and engagement are of a somewhat moderate

nature.

The individual may exhibit a delayed response to sensory stimuli, which could potentially be

accompanied with auditory processing delays.

In terms of perceptual and cognitive abilities, the individual demonstrates a restricted capacity to

adhere to basic instructions and exhibits minimal awareness of safety precautions.

III. OUTCOME MEASURE SUMMARY – Peabody Developmental Motor Scales-II:

The raw score for reflexes in individuals under 12 months of age can be converted to an age

equivalent, percentile, and standard score. The above sequence of numbers, 5 5 25 x, pertains to

the concept of stationary skills. The above sequence of numbers, namely 32, 9, 75, and 12,

pertains to the topic of locomotor skills. The data provided consists of four numerical values: 30,

6, 37, and 9. These values pertain to the domain of object manipulation, specifically for those
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who have been engaged in this activity for a period exceeding 12 months. The sum of standard

scores is 29.

The Gross Motor Quotient of the individual is 98.

The percentile rank for gross motor skills is 45.

IV. ASSESSMENT SUMMARY:

The individual in question is an 8-month-old child, both chronologically and adjusted for their

age. The patient presents to the physical therapy evaluation with delayed gross and fine motor

skills, limited reactivity to stimuli, and modest regulatory problems..

V. RECOMMENDATIONS / GOALS:

A. Recommendations:

The patient undergoes weekly physical therapy sessions, adheres to a daily Home Exercise

Program (HEP), and attends routine pediatric check-ups for monitoring purposes.

B. ENVIRONMENTAL FACTOR to consider:

To foster an engaging domestic setting, it is recommended to furnish a dynamic home

environment replete with interactive toys and activities..

C. PERSONAL FACTOR to consider:

Promote active parental engagement in everyday therapeutic exercises..

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D. GOALS:

a. 3 long-term goals (6 months):

Enhanced head and trunk stability whilst sitting.

Improved proficiency in grasping and manipulating objects.

There is an observed augmentation in vocalization and reactivity to external stimuli.

INTERVENTION PLANNING:

One area of focus in therapeutic interventions is sensory stimulation activities. These activities

aim to engage and stimulate the senses in order to promote cognitive, emotional, and physical

well-being.

To promote sensory development, it is recommended to incorporate daily exercises that involve

tactile and auditory stimulation. These exercises may include utilizing toys with various textures

and engaging in activities that involve playing calming music.

The recommended time frame for this activity is 15 minutes, to be performed twice day.

Motor skill development exercises are an essential component of physical education programs.

These exercises focus on enhancing the coordination, control, and precision of movements
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performed by individuals. By engaging in motor skill development exercises, individuals can

improve their ability to do various physical activities,

To enhance gross motor skills, it is recommended to incorporate daily exercises that specifically

focus on developing head and trunk control. These exercises should encompass supervised

tummy time and aided sitting practice.

The recommended time frame for this activity is 20 minutes, to be performed twice day.

The influence of parental education and support on children's development.

This document aims to present comprehensive guidelines for the Home Exercise Program (HEP)

to ensure accurate execution within a home setting.

It is highly recommended to foster parental engagement in treatment sessions as a means to

bolster developmental advancements.

Provide recommendations for using adaptive strategies to enhance the development of motor

skills in the context of everyday activities.

Please furnish a printed outline of the High Energy Physics (HEP) topic, accompanied by visual

aids and comprehensive descriptions, to facilitate convenient referencing.

It is recommended to implement regular follow-up procedures in order to effectively monitor the

progress of the program and make any necessary adjustments as needed.

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In summary, the story of Leo underscores the significant importance of

early intervention and parental support in facilitating a child's developmental advancement. The

objective is to enhance Leo's head and trunk control, grasp and object manipulation abilities, and

responsiveness to stimuli by employing a comprehensive strategy that incorporates sensory

stimulation, targeted motor skill exercises, and consistent parental involvement. The partnership

between the healthcare team and Leo's family is crucial in guaranteeing the effective execution

of the recommended strategy. Through diligent observation and timely modifications, it is

expected that Leo will attain noteworthy developmental milestones, hence facilitating a more

captivating and interesting childhood encounter.