Plan of Care for E.P.

Yaisa Paxtor

Delaware Technical & Community College

NUR 320: Health Assessment

Mrs. Lind

April 21th , 2024

 Plan of Care for E.P.

E.P. is a 16-year-old male who has a past medical history of childhood asthma, he has

also broken his left arm however is unsure what type of fracture occurred. He has a family

history of hypertension, asthma, diabetes, hypercholesteremia, lupus, chronic kidney disease,

alcoholism, depression, and anxiety. Through my initial assessment, I was able to identify his

living status, which is with his parents and siblings. He did not claim to have any issues

economically or socially, and he stated feeling safe at home. He works about 3-4 times a

week at a restaurant and tries to work out about 4-5 times a week. He is currently a Junior in

high school and states he does not have any trouble in school. However, he did report some

trouble sleeping at night he also reported tooth pains and reported not seeing a dentist in a

couple of years due to lack of insurance.

While looking at my patient as a whole I decided to prioritize his concerns with sleeping

and dental care. He stated that he did not have health insurance and that his parents pay out

of pocket which limits the care he needs. He also admitted not having healthy eating habits

from working at a restaurant he sees the easy way out of dinner most nights with his free

meal.

As a 16-year-old E.P. should be getting an average of 8-10 hours of sleep for every 24

hours, according to the Centers for Disease Control and Prevention. (CDC, 2020) E.P. said he

is getting an average of 6-7 hours when able to fall asleep properly. However, he also stated

he works night shifts after school some nights and also has homework on most nights,

resulting in late-night studies, then trying to fall asleep gets complicated. He has resorted to
melatonin, which according to Nancy Fliesler from Boston’s Children's Hospital, melatonin

should never be used as a “stand-alone” solution and should be accompanied by behavioral

interventions. (Fliesler, 2022) I have provided education about avoiding screen time before

bed or changing his work schedule to only weekends could potentially help E.P. However,

with that being said I have referred him to see his primary care provider. By following up

with PCP he will be able to find more resources to help his sleeping habits. His overall goal

is to gain good sleeping habits and have decent nights of sleep.

E.P. states he has not seen a dentist in about 3-4 years. He stated having toothaches when

eating sweets and cold things. According to Jasmine Reese from Johns Hopkins, she wrote,

that about 13% of adolescents have at least one untreated cavity. (Reese, 2023) I educated the

patient and guardian about the importance of dental health and yearly checkups and

cleanings. I will be referring E.P. to the Southern Delaware Dental Specialist in Georgetown,

DE. This will hopefully prevent E.P. from getting an infected tooth and prevent further

health complications.

One of the last concerns I had with E.P. was his eating habits, as his guardian stated he

eats a lot of unhealthy foods and sugary drinks. The patient also self-reported that he

consumes about one meal every night he works which is about 3-4 nights a week. With a

family history of diabetes, my concerns would be him developing diabetes. So annual A1C

checks can be important. I would like for him to follow up with a dietician to discuss healthy

eating habits. We have developed a goal where he would only like to eat at his place of work

once a week if able to avoid any more.

 Overall, even though E.P. is living a decent lifestyle he still had health issues that had to

be addressed. I think I would want to know things such as a lack of medical insurance. From

that one factor, it can cause so many other issues in his case a lack of dental care. He also

needed help with sleep which without my initial questionare I would have never been able to

assess him and his physical appearance. His eating habits are also something he would like to

improve since he is at higher risk for hypertension, diabetes, and HLD. His care plan will

involve following up with his PCP and a dentist to solve/prevent health issues.
 References

Centers for Disease Control and Prevention. (2020, September 10). Sleep in Middle and high

school students. Centers for Disease Control and Prevention.

https://www.cdc.gov/healthyschools/features/students-sleep.htm

Fliesler, N. (2022, June 13). Melatonin for kids: Is it effective? is it safe?. Boston Children’s

Answers. https://answers.childrenshospital.org/melatonin-for-children/

Reese, J. (2023, December 13). Oral Hygiene in Adolescents. Johns Hopkins Medicine.

https://www.hopkinsmedicine.org/health/wellness-and-prevention/oral-hygiene-in-

adolescents