7.19 Learning Activities

Autism Spectrum Disorder^[1]

Please use the following information to help answer Questions 1-6

Name	Age	Gender	DOB	Code	Allergies	Weight	BMI
Diego Hernandez	8	Male	05/14/2015	Full Code	Peanuts, Amoxicillin	25 kg	16.5

Handoff Report

1446: I am giving you a report on Diego Hernandez, an 8-year-old male with autism spectrum disorder currently receiving home health care. Diego struggles with sensory overload in his home environment and displays repetitive behaviors. He communicates mainly through gestures and picture cards and can become agitated with changes in routine. His growth charts show a recent decline, so we are monitoring his nutritional intake closely. Today, Diego has been experiencing more frequent meltdowns and self-injurious behaviors. He bangs his head and scratches his face when he gets frustrated. He continues to avoid eye contact and resists physical touch, making assessments challenging.

Vital signs: 

• Temperature 98.0 F
• Heart rate 90 bpm,
• Respirations 20 breaths/min
• Blood pressure 105/70 mmHg
• Oxygen saturation 98% on room air

Recommendations for your shift are included in the plan below.

History & Physical

History

• Diagnosed with autism spectrum disorder at age three.
• History of frequent meltdowns triggered by changes in routine.
• Communication primarily through gestures and picture cards. Limited verbal communication.
• Sensory sensitivities: Sensitive to loud noises, bright lights, and certain textures.
• Difficulty transitioning between activities.
• Family history of anxiety and depression.
• Recent decline in growth chart percentiles.

Physical Examination

• Appears anxious, avoids eye contact, and resists physical touch.
• Engages in repetitive rocking and hand-flapping motions.
• Appears thin and potential for nutritional deficiency based on recent growth chart decline.
• Mother reports head-banging and face-scratching with frustration and stimulation overload

Assessment/Medical Diagnoses

•       Autism spectrum disorder.
•       At risk for nutritional deficiency based on growth chart decline.

Plan

• Implement sensory-friendly strategies to reduce overstimulation and promote calmness.
• Develop and follow a consistent daily routine to minimize anxiety and behavioral issues.
• Utilize alternative communication methods, such as picture exchange systems or sign language.
• Provide positive reinforcement and rewards for appropriate behaviors and successful transitions.
• Collaborate with the family to create a supportive and structured home environment.
• Monitor growth and development regularly, addressing any concerns promptly.
• Provide education and resources to the family regarding autism spectrum disorder and available support services.
• Encourage social interaction through playgroups or therapy sessions.
• Address potential feeding difficulties and work with a registered dietician to ensure adequate nutritional intake.

1. Based on Diego’s history and current presentation, what priority problem should the home health care nurse focus on during their shift?

a. Risk for self-injury related to head banging and scratching.

b.  Impaired social interaction related to limited eye contact and verbal communication.

c.  Imbalanced nutrition: less than body requirements related to recent growth chart decline.

d.  Sensory overload related to sensitivity to loud noises and bright lights.

2. The home health care nurse recognizes that Diego is exhibiting nonverbal signs of pain. Based on Diego’s history and developmental stage, what is the most appropriate way to assess his pain level?

a. Asking Diego to point to a picture of a face that represents his pain level.

b. Using a numeric pain scale to rate his pain from 0 to 10.

c. Observing Diego’s facial expressions for signs of grimacing or wincing.

d. Asking Diego’s mother to interpret his nonverbal cues and provide a pain rating.

3. Which short-term goal would be most appropriate for Diego’s care plan related to his self-injurious behaviors?

a. Diego will completely cease all self-injurious behaviors within 24 hours.

b. Diego will demonstrate one alternative coping mechanism when feeling agitated.

c.  Diego will verbally express his needs and frustrations instead of engaging in self-injury.

d. Diego will independently identify triggers for his self-injurious behaviors and modify his environment.

4.  After implementing sensory-friendly strategies, the nurse noted Diego’s agitation decreased slightly. How would the nurse document the evaluation of these interventions?

a. Sensory strategies were successful in completely resolving Diego’s agitation.

b. Diego’s agitation decreased from highly agitated to mildly agitated following the implementation of sensory strategies, including dimming lights and providing noise-canceling headphones.

c. Diego continues to engage in repetitive rocking motions despite sensory interventions.

d. Sensory strategies were ineffective in managing Diego’s agitation.

5.  Diego’s mother expresses concern about his nutritional intake, noting he often refuses to eat foods with certain textures. What is the nurse’s most appropriate action to address this concern?

a. Encourage Diego to eat a variety of foods regardless of his preferences to improve nutrition.

b. Refer Diego to a registered dietitian to develop a meal plan that considers his sensory sensitivities and nutritional needs.

c. Suggest providing Diego with liquid nutritional supplements to replace meals.

d. Teach Diego’s mother to implement strict mealtime routines to enforce better eating habits.

6. During the nurse’s visit, Diego becomes visibly frustrated and starts banging his head. What is the nurse’s immediate priority intervention?

a. Firmly hold Diego to prevent further injury and attempt to comfort him.

b. Redirect Diego to a calming activity, such as rocking in a sensory chair.

c. Place soft padding around Diego to minimize injury and allow him to calm down independently.

d. Call Diego’s mother to assist in managing his frustration.