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  • Clinical Log For Pediatrics

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    This document contains a clinical log for a pediatric patient including the patient's initials, sex, age, diagnosis, medical history, surgery details, diet, IV fluids, medications, vitals, system assessments, developmental stage, immunizations, and nursing care plan. The nursing care plan addresses three nursing diagnoses, expected outcomes, and a minimum of three evidence-based interventions for each diagnosis. The nurse evaluates whether the expected outcomes were met and if interventions need changing.

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    Clinical Log for Pediatrics

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    This document contains a clinical log for a pediatric patient including the patient's initials, sex, age, diagnosis, medical history, surgery details, diet, IV fluids, medications, vitals, system assessments, developmental stage, immunizations, and nursing care plan. The nursing care plan addresses three nursing diagnoses, expected outcomes, and a minimum of three evidence-based interventions for each diagnosis. The nurse evaluates whether the expected outcomes were met and if interventions need changing.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    45 views3 pages

    Clinical Log For Pediatrics

    Uploaded by

    foundations2000
    This document contains a clinical log for a pediatric patient including the patient's initials, sex, age, diagnosis, medical history, surgery details, diet, IV fluids, medications, vitals, system assessments, developmental stage, immunizations, and nursing care plan. The nursing care plan addresses three nursing diagnoses, expected outcomes, and a minimum of three evidence-based interventions for each diagnosis. The nurse evaluates whether the expected outcomes were met and if interventions need changing.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 3

    NRBS 411 Clinical Log for Pediatrics

    Name:____________________________________________________ Date: __________________________


    Initials of child:_________________________ Sex__________________________ Age__________________
    Primary diagnosis __________________________________________________ #of days hospitalized_______
    Past medical history:_________________________________________________________________________
    __________________________________________________________________________________________
    Surgery:______________________________________________________________ Post-op day: __________
    Special procedures:__________________________________________________________________________
    Diet: _____________________________ IVF (type): ________________________________ Rate:__________

    IV Site:
    __________________________________________________________________________________
    Medications (including indications for use, dose, route, frequency)
    Meds

    Use/category

    Dose

    Route

    Freq.
    Side effects

    Objective:
    Yesterdays weight:_______________ Todays wt.: ___________ +/-: _________Wt percentile: ____________
    Length/height _________________Temperature:______________ Pulse:__________ Respirations:__________

    B/P______________ 02
    Saturation:_____________________________________________________________
    Systems Assessment
    1/11

    2
    Cardiovascular:
    Respiratory:
    GI:
    GU:
    Integument (include status of IV site):
    Neurological:
    Musculoskeletal:
    Erickson stage of development:
    Is the child at his/her appropriate developmental stage. Describe:
    Immunization: (State the vaccinations the child should have received or has already received.)
    --------------------------------------------------------------------------------------------------------------------------------------Nursing Care Plan
    Nursing Problem #1:
    Expected Outcome:
    Plan/Interventions (Minimum of 3 interventions, identify if it considered evidence based practice. Provide
    summary and reference for the site (eg. printout from internet).

    Evaluation of Expected Outcome (Did you or did you not meet the expected outcome, are you going to change
    your interventions?):

    Nursing Care Plan (cont)


    Nursing Problem #2:
    Expected Outcome:

    1/11

    3
    Plan/Interventions (Minimum of 3 interventions, identify if it considered evidence based practice. Provide
    summary and reference for the site (eg. printout from internet).
    Evaluation of Expected Outcome (Did you or did you not meet the expected outcome, are you going to change
    your interventions?):

    --------------------------------------------------------------------------------------------------------------------------Nursing Diagnosis #3:


    Expected Outcome:
    Plan/Interventions (Minimum of 3 interventions, identify if it considered evidence based practice. Provide
    summary and reference for the site (eg. printout from internet).

    Evaluation of Expected Outcome (Did you or did you not meet the expected outcome, are you going to change
    your interventions?):
    --------------------------------------------------------------------------------------------------------------------------Nurses Notes:

    1/11

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