np step-down nicu

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West Visayas State UniversityCOLLEGE OF NURSING

La Paz, Iloilo City

NURSINGPROCESS

STEP-DOWN NICU

Submitted by:Charles Jebb B. Juanitas

BSN 2 – CRLE Group 4

Submitted to:Oliver P. Villanueva, RN

Clinical Instructor

February 17, 2011

VisionWVSU as one of the top universities in Southeast Asia.

Mission To produce globally competitive individuals who are life-

long learners.



West Visayas State UniversityCOLLEGE OF NURSING

La Paz, Iloilo CityNURSING PROCESS

(Pedia)

I. VITAL INFORMATIONName: Date of Interview:Age: Informant:Sex: Relationship to patient:Address:Date and Time Admitted:Ward:Bed No.:Religious Affiliation:Physician 's Initial:Impression/Diagnosis:Name of Mother: Age:Educational Attainment:Occupation:Name of Mother: Age:Educational Attainment:Occupation:Approximate income of the family:

II.CLINICAL ASSESSMENT

II.A. NURSING HISTORY1. History of Present Illness

a. Usual Health Status

b. Chronologic Story



c. Relevant Family History

d. Disability Assessment

2. Personal Historya. Prenatal

Mother 's general health:Medications taken during pregnancy:Pain, bleeding, threatened abortion: None: Yes: Specify:

b. Birth

Duration and circumstances of labor:Analgesia used:Delivery: Home: Hospital: Type:Complications:Birth weight:AOG:

c. Neonatal: Feeble: Vigorous:Resuscitated: Cyanosis:Convulsions: Hemorrhage:Pallor: Dyspnea:

3. Familial HistoryBirth order of the child: Total number of siblings:Number of living siblings: Type of housing:Serious diseases, illness of siblings:Congenital disease among siblings:Death of siblings: Cause of death:Heredo-familial diseases:

4. Past Health Statusa. Childhood Illnessb. Immunization Status

Agereceived

Datereceived

1 st dose 2 nd

dose3 rd dose Booster

1Booster 2

OPVDTPMMRBCGHepa AHepa BCPOthers(specify

)

c. Allergies:d. Accidents and Injuries:e. Hospitalization for serious Illness:f. Medications:



5. Family History of Illness

6. Patient 's Expectationsa. What does she expect to occur during this hospitalization?

b. What does she expect during nursing care?

7. Patterns of Functioning

a. Breathing Pattern

Respiratory Problems:

Usual Remedy:Manner of Breathing:

b. Circulation

Usual blood pressure:Any history of chest pain, palpitations, coldness of extremities, etc.

c. Sleep Pattern

Usual Bedtime:

Naps:Bedtime rituals:Problems regarding sleep:Usual remedy:

Total number of hours of sleep:

d. Drinking patterns

i. Kinds of fluid in 24H/ Amount in mL or number of bottles:

e. Nutritional historyFeeding

Bottle-feed: Breastfeed: Mixed:Supplementary feeding: Age started:Vitamins: Type:

Amount:Food likes:Food dislikes:Beliefs and fallacies:

f. Elimination Patterns

1. Bowel MovementFrequency:Problems or Difficulties:



Usual Remedy:

2. UrinationFrequency:Problems or Difficulties:

Usual Remedy:

g. Exercise

h. Personal Hygiene

1. BathType:Frequency:Time of day:

i. Recreation:

j. Health Supervision:

II.B. CLINICAL INSPECTION

II.B.1. Vital Signs: Date and Time Taken:Temperature: PR:BP: RR:

II.B.2. Height:II.B.3. Weight:

II.B.4. PHYSICAL ASSESSMENT

General Appearance:

A. INTEGUMENTARY SYSTEM

B. RESPIRATORY SYSTEM



C. CARDIOVASCULAR/CIRCULATORY SYSTEM

D. GASTROINTESTINAL SYSTEM

E. GENITO-URINARY SYSTEM

F. REPRODUCTIVE SYSTEM

G. ENDOCRINE SYSTEM

H. MUSCULOSKELETAL SYSTEM

I. LYMPHATIC SYTEM

J. HEMATOPOEITIC SYSTEM



K.REFLEXES

Reflexes How elicited Expectedresponse

Agediminished

Evaluation

Blinking

reflex

Pupillaryreflex

Rootingreflex

Suckingreflex

Swallowingreflex

Extrusionreflex

Gag reflex

Palmar grasp

reflex



Plantargrasp reflex

Tonic neckreflex

Babinskireflex

II.C. DEVELOPMENTAL ASSESSMENT

Found in Textbook ActualObservation

Significance

A. GrossMotorDevelopment

B. FineMotorDevelopment



C. SensoryDevelopment

D. PsychosocialDevelopment &Socializati

on

E. PsychosexualDevelopment

F. SpiritualDevelopment

G. Cognitive/IntellectualDevelopm

ent



H. Language/ SpeechDevelopment

II.D. NURSING PROGRESS NOTES



II.F. OTHER SOURCE OF LABORATORY DATA

Name of Examination:

Definition:

Preparation:

Purpose:

Date:

Results

1/30/111/22/11

Normal values Significance

Hemoglobin massconcentration

135-180 g/L

Erythrocytevolumefraction

0,40-0,54 L/L

Erythrocytenumberconcentrati

4,6-6,2 x 10 12 /L



on

Leucocytenumberconcentration

4,5-11,0 x 10 9L

Neutrophilnumberfraction

Segmenter 0,50-0,70

Stab 0,02-0,05

ErythrocyteSedimentation Rate

Lymphocyte number

fraction

0,20-0,40



Thrombocyte numberfraction

150-350 x 10 9/L

II. TEXTBOOK DISCUSSION



III. PROBLEM LIST

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