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. Child’s Reactions to Hospitalization (1 point)

6. Formulate a Nursing Diagnosis Based on Child’s Reaction to Hospitalization (1 point)

7. Parent’s Reaction to Child’s Hospitalization (1point)

8. Formulate Nursing Diagnosis Based on Parent’s Reaction to Hospitalization (1 point)

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 COURSE: RNSG 2161 PEDIATRIC CARE PLAN
PHYSICAL ASSESSMENT (18 points)
NEUROLOGIC ASSESSMENT CARDIOVASCULAR
Pupils Size ++= Brisk Heart Tones: □strong □regular □muffled □murmur
Right Reaction + = Sluggish Heart Sounds: □ regular □ irregular
Size
- = No reaction Color: □pink □ pale □ mottled □ dusky □ cyanotic
Left Reaction
C = Eye closed □ashen □jaundice
Eyes Spontaneously 4
by swelling Peripheral Pulses: □ palpable □ strong □ weak
Open To speech 3 □regular □ irregular
To pain 2 Extremity temperature: □ hot□ warm □ cool □ cold
GLASGOW COMA SCALE

None 1 Capillary refill: □</-2 seconds □>2 seconds

Best Obeys commands 6 Edema: □absent □peripheral □dependent
motor Localizes pain 5 □generalized □ pitting Location
response of:_______________
Flexion withdrawal 4
Pulses: RAD FEM POP DP PT
Flexion abnormal 3 Left ___ ____ ___ ___ ___
Extension 2 Pupil scale Right ___ ____ ___ ____ ____
None 1 (mm)
RENAL
Bladder Distention: □ no□ yes
Best >2 year <2 years
response
Voiding: □continent□ incontinent □diaper □stent
Orientation 5 5 Smiles, listens, follows
to □catheter
Confused 4 4 Cries, consolable
auditory Urine appearance: □ clear □ cloudy □ yellow
Inappropriate words 3 3 Inappropriate persistent cry
and/or □amber □ blood-tinged □ bloody □ anuric
Incomprehensible words 2 2 Agitated, restless
visual Output:________________________
stimulus None 1 1 No response
SAFETY
Endotracheal tube or trach T
Check all that apply:
COMA SCALE TOTAL □ID bracelet on □ bed wheels locked
□ call light accessible
HAND GRIP: MUSCLE TONE: FONTANEL/WINDOW: □ allergy band on □ code sheet @ FOB
Equal Normal Soft
Unequal Arching Flat □ parent instructed on siderail safety
R_____L Spastic Sunken □ parent instructed on infant positioning
Weakness Flaccid Tense □ seizure protocol
Weak Bulging MUSCULOSKELETAL
Decorticate Closed
LOC: Decerebrate Other_____________
Movement:
Alert/oriented x4 Other___________ □ moves all extremities w/ appropriate range
Sleepy □ limited range in: □ LUE □ RUE □ LLE □ RLE
Irritable EYEMOVEMENT: MOOD/AFFECT: □ tremors □ clonus □ postures
Comatose Normal Happy
Disoriented Nystagmus Content
Self Care:
Combative Strabismus Quiet Withdrawn □ self □ assists □ complete □ age appropriate
Lethargic Other____________ Sad Appliances:
Awake Flat □ splints □ AFO
Sleeping Hostile Traction:
Drowsy
Agitated □ 90/90 □ Other
PULMONARY GASTROINTESTINAL
Working of Breathing: □ unlabored□ deep □shallow □rapid Abdomen: □ soft □ tense □ rigid □ distended
□ labored □ reactions □ nasal flaring □ grunting □ stridor □tender □ c/o nausea □ vomiting
Cough: □ absent □ weak □ non-productive □ productive Bowel Sounds: □ active □ hyperactive □
Sputum: □ clear □ white □ yellow □ brown □ green □ blood-tinged □ frank blood hypoactive □ absent
AMT: □ small □ mod. □ large NG/GT/GB: □ NGT placement verified □ patent
Breath Sounds: upper airway congestion □ to gravity □ clamped □ elevated □ to suction
Fn crckl = fien crackles Crs crckl = course crackles □ to feeding
RU = □ clear □ Fn crckl □Crs crckl □ wheeze □ Diminish Suction: □ none □ low □ high□intermitted
RM= □ clear □ Fn crckl □Crs crckl □ wheeze □ Diminish □continous
RL= □ clear □ Fn crckl □Crs crckl □ wheeze □ Diminish Gastric Drainage Appearance: □ clear □ bloody
LU= □ clear □ Fn crckl □Crs crckl □ wheeze □ Diminish □ bilious
LL= □ clear □ Fn crckl □Crs crckl □ wheeze □ Diminish Ostomy:________(specify type) □ patent
Oxygen support: □ none □ bag secure □ stomas appears healthy
□____L/minute via: □ NC □ face mask □ trach collar Stool:
Fi02 ____ % via: □ NC □ face mask□ tent □ venture □ none □ within normal limits for patient □ diarrhea
□non-rebreather □ T-collar □ CPAP □ BiPap □ ETT color: _________% diet taken:
Trach: □ Bivona □ Shiley □ Size:________ consistency:__________ Emesis:___________
P.O. Intake ____________________________
NUTRITION
Diet:____________________________________
Snack:___________________________________
Fluids:___________________________________
TPN?:___________________________________

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COURSE: RNSG 2161 PEDIATRIC CARE PLAN
INTEGUMENTARY Narrative Notes:
Skin Description:
□ hot □ warm □ dry □ cool □ clammy □ diaphoretic
□ color appropriate for patient ethnicity
Mucous Membrane:
□ cracking □ pink □ pale □ thrush
Skin Turgor: □ elastic □ sluggish □ tenting
Alterations in Skin Integrity: □ rash □ incision □ burn
□pin□ site □laceration□ skin □breakdown □bruise
□decubitus□ abrasion □tube/ drain □sutures □staples
□dressing (type): _______________________________
Incision: □clean □dry □intact □reddened □edema
□separated □draining □covered w/dry, intact dressing

PSYCHOSOCIAL
Family Support: □family □present □extended family present □friends of
family present □alone
Hospitalized Behavior: □makes eye contact □cries □withdraws □sleeps
□asks questions □talks to staff □withdraws from staff □interested in
environment□ play contentedly□ verbally expresses fear □talks to parent
EYES, EARS, NOSE & THROAT
Eyes: □clear □drainage (describe)_____________________
□inflamed □cries tears
Ears: □clear □drainage(describe)___________________________
painful no c/o of pain
Nose: □clear □drainage (describe) __________________________
Throat: □clear□ reddened □difficulty swallowing □painful
PAIN ASSESSMENT
Pain Present? □yes□ no
Location:_____________________________________
Quality: □ crampy □dull □sharp □stabbing
Duration:______________________________________
Child’s words to describe:______________________________________________
___________________________________________________________________
Pain behavior:_______________________________________________
Pain score: _________________________________________________
Intervention: ________________________________________________
Evaluation Follow-up:__________________________________________
IV
IV Site Appearance:___________________________________________
IVF:_______________________________________________________
__________________________________________________________
__________________________________________________________
IV Medications: _____________________________________________
__________________________________________________________
__________________________________________________________
Other:_____________________________________________________
Total Intake this Shift:_________________________________________
Total Output this Shift:________________________________________
I&O
Total for shift: Intake:__________________________________________
Output:_________________________________________
Additional Revelant Data:
__________________________________________________________
___________________________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________

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COURSE: RNSG 2161 PEDIATRIC CARE PLAN

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)
a. Which stage has child achieved? ________________________________

___________________________________________________________________

b. Supportive data? _____________________________________________

___________________________________________________________________
3. Cognitive Development (Piaget)
a. Which stage has child achieved? ________________________________

___________________________________________________________________

b. Supportive data? _____________________________________________

___________________________________________________________________
4. Moral Development (Kohlberg)
a. Which stage has child achieved? ________________________________
___________________________________________________________________

b. Supportive data: _____________________________________________

___________________________________________________________________
5. Spiritual Development
a. Which stage has child achieved? ________________________________

___________________________________________________________________

b. Supportive data? _____________________________________________

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COURSE: RNSG 2161 Pediatric Care Plan

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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 COURSE: RNSG 2161 Pediatric Care Plan

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) cite
from textbook

1.

2.

3.

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COURSE: RNSG 2161 Pediatric Care Plan
TEACHING/LEARNING SESSION (CONTINUED)
EVALUATION (3 points)
A. Achievement of learning outcome: Met
Actual child/family behavior as evidence by:
(Provide a description of actual behavior/data supporting achievement of learning outcome)

_______
Actual child/family behavior as evidenced by: Not Met
(Provide a description of actual behavior/data supporting deviation from learning outcome)

B. List two reasons for success of learning outcome:

OR
List two reasons for deviation of learning outcome:

DISCHARGE INSTRUCTIONS: (2 points)

A. To child:

B. To parent:

C. Identify a specific referral/resource for patient/family:

D. Child/family ability to access community resources:

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COURSE: RNSG 2161 Pediatric Care Plan
MEDICATIONS
LIST THE CURRENT MEDICATION ORDERS FOR THE PATIENT AND STATE WHY THE
MED IS VEING GIVEN. SHOW THE MATHEMATICAL CALCULATION FOR SAFE DOSAGE.
SAFE DOSAGE- WHY IS DRUG GIVEN TO THIS
MEDICATION YES/NO/WHY? PATIENT

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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 NURSING DIAGNOSIS INTERVENTIONS Evidence-based Evaluation
research
Individualize to this child! (6pts) cite references (9pts) S.O.A. P. Format (4pts)

Physiological NANDA: (2pts) Assessment: S: (Patient perceptions and

List all ongoing assessments to expressions)
_______________________
perform: _______________________
_______________________
_______________________
_______________________
_______________________
O: (Measurements,
observations, and diagnostic
data)
_______________________
_______________________
List all nursing interventions to _______________________
promote: _______________________
_______________________
_______________________
_______________________

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Expected Outcome(s): (2pts) A: (Interpretations &
(Must be patient centered and conclusions from S & O;
measurable within time frame) progress toward outcome &
status of nursing diagnosis)
_______________________
_______________________
_______________________
_______________________
List all teaching:
_______________________
_______________________
P: (Indicate modifications for
update of plan)
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
 NURSING DIAGNOSIS Interventions Evidence-based Evaluation
research
Individualize to child (6pts) cite references (9pts) S.O.A.P. Format (4pts)

Psychosocial NANDA: (2pts) Assessment: S: (Patient Perceptions and

expressions)
List all ongoing assessments to
_______________________
perform _______________________
_______________________
_______________________
_______________________
_______________________
O: (Measurements,
observations, and diagnostic
data)
_______________________
_______________________
List all nursing interventions to _______________________
promote: _______________________
_______________________
_______________________
_______________________

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A: (Interpretations &
Expected Outcome(s): (2pts) conclusions from S & O;
(Must be patient centered and progress toward outcome &
measurable within time frame) status of nursing diagnosis)
_______________________
_______________________
_______________________
_______________________
List all teaching: _______________________
_______________________
_______________________
P: (Indicate modifications or
update of plan)
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
 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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