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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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