Pedi CarePlan

8/6/2019 Pedi CarePlan

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COURSE: RNSG 2161 Pediatric Care Plan

Student Clinical date(s)

Date of Admission

Patient age in years Months Days

Sex Weight Percentile

Temp/method Height Percentile Head circumference Percentile

B/P location Apical heart rate Respiratory rate

Premie: Yes No Allergy

1. Medical Diagnosis (0)

2. Definition (1 point)

3. Pathophysiology (1 point) (May write on back of page)

4. Precipating Factors for Hospitalization (Reason for Admission) (1point)

5. Childs Reactions to Hospitalization (1 point)

6. Formulate a Nursing Diagnosis Based on Childs Reaction to Hospitalization (1 point)

7. Parents Reaction to Childs Hospitalization (1point)

8. Formulate Nursing Diagnosis Based on Parents Reaction to Hospitalization (1 point)


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COURSE: RNSG 2161 PEDIATRIC CARE PLAN

PHYSICAL ASSESSMENT (18 points)NEUROLOGIC ASSESSMENT

GLASGOW

COMASCALE

PupilsRight

Size

Reaction

Left

Size

ReactionEyesOpen

Spontaneously 4

To speech 3

To pain 2

None 1

Bestmotorresponse

Obeys commands 6

Localizes pain 5

Flexion withdrawal 4

Flexion abnormal 3

Extension 2

None 1

Bestresponsetoauditoryand/or

visualstimulus

>2 year


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INTEGUMENTARYSkin Description: hot warm dry cool clammy diaphoretic color appropriate for patient ethnicity

Mucous Membrane:

cracking pink pale thrushSkinTurgor: elastic sluggish tentingAlterations in Skin Integrity: rash incision burnpin site laceration skin breakdown bruisedecubitusabrasion tube/ drain sutures staplesdressing (type): _______________________________Incision: clean dry intact reddened edemaseparated draining covered w/dry, intact dressing

Narrative Notes:

PSYCHOSOCIALFamily Support: family present extended family present friends offamily present alone

Hospitalized Behavior: makes eye contact cries withdraws sleepsasks questions talks to staff withdraws from staff interested inenvironment play contentedly verbally expresses fear talks to parent

EYES, EARS, NOSE & THROATEyes: clear drainage (describe)_____________________inflamed cries tears

Ears: cleardrainage(describe)___________________________painfulnoc/oof painNose: clear drainage (describe) __________________________Throat: clear reddened difficulty swallowing painful

PAINASSESSMENTPain Present? yesnoLocation:_____________________________________

Quality: crampydullsharpstabbingDuration:______________________________________Childs words to describe:_________________________________________________________________________________________________________________

Pain behavior:_______________________________________________Pain score: _________________________________________________Intervention: ________________________________________________

Evaluation Follow-up:__________________________________________

IVIV Site Appearance:___________________________________________IVF:___________________________________________________________________________________________________________________________________________________________________________IV Medications: _________________________________________________________________________________________________________________________________________________________________Other:_____________________________________________________Total Intake this Shift:_________________________________________Total Output this Shift:________________________________________

I&OTotal for shift: Intake:__________________________________________

Output:_________________________________________Additional Revelant Data:

_____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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PHYSICAL AND DEVELOPMENTAL ASSESSMENT OF THE CHILD (5 points. total)

A. Personality and Mental Function

1. Psychosexual Development (Freud)

a. Which stage has child achieved? ________________________________

___________________________________________________________________

b. Supportive data? _____________________________________________

___________________________________________________________________

2. Psychosocial Development (Erikson)


___________________________________________________________________


___________________________________________________________________

3. Cognitive Development (Piaget)


___________________________________________________________________


___________________________________________________________________

4. Moral Development (Kohlberg)


___________________________________________________________________

b. Supportive data: _____________________________________________

___________________________________________________________________

5. SpiritualDevelopment


___________________________________________________________________



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B. Growth and Development Assessment (continued)

Compare and contrast selected aspects of development. (5points)Age: Years Months Days

Child Textbook Standard

Number of teeth:

temporary

permanent

Nutritional requirements:

Fluid maintenance/day

Kcal/day

protein

Eye-hand coordination

Attention span (give example)

Motor coordination and activity-(give examples)

Gross

Fine

Play activities

Relationship with peers

Sexual curiosity

Relationship with family

Language development

Interest in religion

Types of fears

Degree of independence


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TEACHING/LEARNING SESSION

ASSESSEMENT

State patient/family teaching needs with rationale: (1point)

1.

2.

Cultural considerations of patient/family: (1point)

ANALYSIS (1point)

NANDA Statement

Knowledge Deficit in related to(specify)

As evidenced by (AEB)

PLAN(State one Learning outcome:) (1point)

( )+ ( )+ ( ) + ( )(Patient Behavior) (Criterion of Performance ) (Time) (Condition)

NURSING INTERVENTIONS

Teaching Strategy (1point)

Teaching Interventions (must include play and supported by evidenced-based practice) (6 points) citefrom textbook

1.

2.

3.


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MEDICATIONS

LIST THE CURRENT MEDICATION ORDERS FOR THE PATIENT AND STATE WHY THEMED IS VEING GIVEN. SHOW THE MATHEMATICAL CALCULATION FOR SAFE DOSAGE.

MEDICATIONSAFE DOSAGE-YES/NO/WHY?

WHY IS DRUG GIVEN TO THISPATIENT

1.

2.

3.

4.

5.

6.

SHOW CALCULATION ON BACK OF PAGE: (2 points)

FORMULATE A NURSING DIAGNOSIS R/T DRUG THERAPY: (1 points)


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Evaluation

S.O.A.P

.Forma

t

(4pts)

S:(Patientperceptionsand

express

ions)

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

O:(Mea

surements,

observa

tions,anddiagnostic

data)

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

A:(Inter

pretations&

conclusionsfromS&O;

progresstowardoutcome&

statuso

fnursingdiagnosis)

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

P:(Indic

atemodificationsfor

updateofplan)

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

_______________________

Evidence-based

research

citere

ferences

(9pts)

INTERVENTIONS

Individualize

tothisc

hild!

(6pts)

Assessment:

Lista

llong

oingassessmen

tsto

perform:

Lista

llnur

sing

interven

tions

to

promo

te:

Lista

llteac

hing:

NURSING

DIAGNOSIS

PhysiologicalNANDA:(2p

ts)

Expec

tedOutc

ome

(s):(2p

ts)

(Mustbepatientcenteredand

measurablewithintimeframe)


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Eval

uation

S.O.A.P.

Form

at

(4pts)

S:(PatientPerceptionsand

expressions)

___________

____________

___________

____________

___________

____________

___________

____________

___________

____________

___________

____________

O:(Measurem

ents,

observations,

anddiagnostic

data)

___________

____________

___________

____________

___________

____________

___________

____________

___________

____________

___________

____________

___________

____________

A:(Interpretations&

conclusionsfromS&O;

progresstowa

rdoutcome&

statusofnursingdiagnosis)

___________

____________

___________

____________

___________

____________

___________

____________

___________

____________

___________

____________

___________

____________

P:(Indicatem

odificationsor

updateofplan)

___________

____________

___________

____________

___________

____________

___________

____________

___________

____________

___________

____________

Evid

ence-based

research

citereferences

(9pts)

Interventions

Individua

lizeto

child

(6pts)

Assessment:

Lista

llongoing

assessmen

tsto

perform

Lista

llnurs

ing

interven

tions

to

promo

te:

Lista

llteac

hing:

NURSING

DIAGN

OSIS

PsychosocialNA

NDA:(2pts)

Expec

tedOu

tcome

(s):(2p

ts)

(Mustbepatientcente

redand

measurablewithintimeframe)


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Associate Degree Nursing Program

Drug Card Format

Student Name: ________________________

Date: _______________________________


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COURSE: RNSG 2161 DRUG CARD FORMAT

DRUG CARD FORMAT

On a full-sized paper using the format displayed below complete drug assigned

throughout semester.

Drug (Generic Name:

Trade Name:

Drug Class:

Major Drug Category:

Drug Action:

Uses:

Side Effects/Adverse Reactions (most common):

Significant Drug interactions:

Route of Administration:

Usual Pediatric Drug Dosage:

Important Nursing Implications for infants and children:

Administration:

Teach:

Teach:

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