Health Assessment
A comprehensive history and physical examination is essential for all well-child visits allowing for minor variations based on the patient’s age (Sullivan, 2012). Addressing any new issues if present would be the first step. The child has been coming to the office since birth, past medical, family, and social history would be updated. A review of systems and comprehensive physical exam will also be completed.NURS 6512 Wk 11: Health Assessment
The health assessment includes growth and developmental screenings to determine if the patient is following a healthy growth and developmental trajectory (Sullivan, 2012). Establishing if the patient has received any immunizations from birth until now should also be included particularly due to parental opposition to immunizations and the likelihood that the patient has not received any. Assessment of attention span and ability to separate from parents is important for school readiness (Sullivan, 2012). Patient safety such as seat belts, booster seats, street safety should be determined while discussing anticipatory guidance. Laboratory data is not necessary at this age unless it is required for a new onset issue. Lastly, discussing other topics anticipatory for this age include knowing full name, address, and phone number; sexual curiosity; household chore participation; and no playing with match (Sullivan, 2016).