peds care plan
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PEDIATRIC CARE PLAN
Patient Data Base
Student__________________________________Instructor__________________________________
No Section is to be left blank without explanation.
ASSESSMENT OF HEALTH PATTERNSPatients Initials
Date of Assessment
Age
Date of Birth
Sex
Race
Source of Information
Reason for Admission
Todays Chief Concern
(Patient, Parent, Nurse)
Present DiagnosisPresent Surgery
Medical History
Surgical History
_________________________________________________
Religion
Primary Caregiver/s and relationship/s
Communication Difficulties
History of Blood Transfusions
Meds taken at Home
Meds Currently Ordered
Prescribed Diet
Current Activity Order
Current PT, OT, or ST ordered
ASSESSMENT
Temperature
Radial Pulse
Apical Pulse
Respirations
Blood Pressure
Pulse OximetryHeight Appropriate for Age?(check developmental graph)
Weight Appropriate for Age?( check developmental graph)
Unable to Assess due to:
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ASSESSMENT DESCRIPTION
General Appearance
Mental status Disoriented Oriented Person Place T
e
Memory Short Term Long Term
Speech Clear Slurred or Stuttered
Allergies Food Medication Seasonal Type of reac
Vision (Include How tested) Normal Impaired Glasses
Reading or
Long-distance
Contacts
Hearing(Include How tested) WNL Impairment Hearing Aids
Olfactory Impaired(Include How
tested)
Taste Impaired( Include How tested)
Unable to Assess above Due To:ASSESSMENT OF FAMILY ROLE PATTERNS
Parental Marital Status
Number of family living in home
Education Level of parents
Parents Occupations
Family Financial Concerns
Cultural/Ethnic Background (Origin
of grandparents)
Religious/Spiritual Practices(Specific
type)
Lifestyle(Child)
Recent Changes in Lifestyle(before hospitalization)
Regular Health Practices MD check-
ups, Immunizations, Meds)
Family Health Promotion
Behaviors(Exercise, Balanced Diet,
Vitamins, Dental Care)
Stress Factors (Family)
Ways of Handling Stress
Emotional Status
Childs Use of Alcohol Street Drugs/Glue Tobacco
Family History of
(include relationship)
Diabetes Heart Disease or
Malformations
Hypertension Kidney
Disease
Mental Illness Substance Abuse Tuberculosis Strokes
Epilepsy Cancer Other
Unable to Assess Due To:
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ASSESSMENT OF ADL PATTERNS
Mobility Independent Dependent Describe
Hygiene
Toileting
Feeding
Dressing
OtherUnable to Evaluate Above Due to
ASSESSMENT OF INTEGUMENT
Where/description/Etiology?
Scars
Lacerations
Ecchymosis
Diaphoresis
Rashes
Ulcerations
Blisters
Other
Draw a Figure and Mark Location of the Above on the Figure
ASSESSMENT OF NUTRITIONAL PATTERNS
Assessment Description
Diet Usual(Home) Hospital
Enteral Feedings
IV Fluids(Fluid and rate if infusion)
IV Site
Loss of Appetite
Nausea
Vomiting
Heartburn
Chewing Problems
Swallowing Problems
Condition of Teeth/Gums/Mucous
Membranes
Skin Turgor
Recent Changes in Weight
Intake and Output(Fluids in and out
your shift)
Unable to Evaluate Above Due To
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ASSESSMENT OF ELIMINATION PATTERNS
Usual Bowel Pattern(at home)
Laxative or Enema Use
Characteristics of Stool(color,
consistency, quantity)
Last Bowel Movement
FlatusBowel Sounds( 4 Quadrants)
Abdomen Soft Distended
Presence of History of
(give Dates)
Incontinence Pain Burning
Frequency Retention Difficulty Void
Drainage Devices
Unable to Evaluate Above due to:
ASSESSMENT OF FLUID/GAS PATTERNS
Color Overall Lips Nailbeds
Color Mucous Membranes Conjunctiva Other
Extremities Temperature Capillary Refill Varicosities Sensatio
Presence or History of
(Give Dates)
Hypertension Ankle/Leg/
Sacral/Periorbital
Edema
Pitting/Nonpitting
Edema
Slow
Healing
Chronic wounds Heart Trouble Phlebitis Other
Breath Sounds
Dyspnea
Cough/Sputum (Frequency/Color,
quantity and tenacity)
Airways Endotracheal Tracheal Ventilator
Presence or History of
(Give Dates)Bronchitis Pneumonia Orthopnea Asth
Wheezing Respiratory Tx Exposure toNoxious
Fumes
Smo(Pks/
#yrs.
Unable to Evaluate Above Due To:
ASSESSMENT OF COMFORT, ACTIVITY/REST AND MOBILITY PATTERNS
Leisure Time Activities
Limits Imposed by Physical
Condition
General Strength
Muscle Tone
ROM (Specify degree of anglelimitation and joint)
Gait
Pain(Pain Scale)
Unable to Evaluate Above Due to:
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TEXTBOOK PICTURE
Medical
Diagnosis:_______________________________Student____________________________________
Definition:
______________________________________________________________________________________
________________
Etiology:
______________________________________________________________________________________
________________
PATHOPHYSIOLOGY
Describe in as much detail as possible, the pathophysiology (Not signs and Symptoms)
underlying the clients medical diagnosis and relate it to nursing needs.
Signs/Symptoms:
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Usual Diagnostic Workup(Tests and exams usually done for this condition):
______________________________________________________________________________________
________________
Usual Medical/Surgical Treatment:
(include Medications & Diet)
______________________________________________________________________________________
________________
Pts Developmental Stage: (According to Erickson)
(Describe Behavior that correlates with age)
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LABORATORY RESULTS
Include those pertinent to nursing and medical diagnoses. Include normal values and client results. Include reason(s) for abnormal findings.
NAME OF TEST NORMAL
VALUES
CLIENTS
RESULTS
RATIONALE FOR THIS CLIENTS
RESULTS
NURSING INTERVENTIONS
(Pre-test, post-test and resulting from test results)
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DIAGNOSTIC STUDIES
Include those pertinent to nursing and medical diagnoses. Include normal parameters and client results. Include reason(s) for abnormal findings
NAME OF TEST NORMAL
VALUES
CLIENT VALUES RATIONALE FOR THIS CLIENTS
RESULTS
NURSING INTERVENTIONS(Pre and Post-test and som
resulting from test results)
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PLAN OF CARE*
DATE:____________________________________ Prioritized Nsg Dx
1.____________________________
NAME____________________________________ 2.____
3.___________________________
CLIENTS INITIALS:_____________
PATTERN
MANIFESTATION
NURSING
DIAGNOSIS
MUTUALLY
DEVELOPED
OUTCOMES
NURSING
INTERVENTIONS
SCIENTIFIC
RATIONALES AND
REFERENCES
EVALUATION AND
MODIFICATION
NANDA
STATEMENT
RELATED TO
AS EVIDENCED BY
Assessment(2)
Actions(4)
Teaching(2)
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PATTERN
MANIFESTATION
NURSING
DIAGNOSIS
MUTUALLY
DEVELOPED
OUTCOMES
NURSING
INTERVENTIONS
SCIENTIFIC
RATIONALES AND
REFERENCES
EVALUATION AND
MODIFICATION
NANDA
STATEMENT(Cont
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