pediatric care plan template
DESCRIPTION
Fill-in Care plan pedsTRANSCRIPT
Ivy Tech Community CollegeNSG 113
Pediatrics Care Plan
Patient Initial _ _ Student Name _____________________
Admission Date _ _ Date(s) of Care_ __ Birth Date__________ Patient Age _ __
Patient Diagnosis _ __Date of Surgery, if applicable___ _ Allergies___________________
Diagnoses_____________________________________________________________________________
Development Appropriate for Age? Yes_____ No_____
Explain_______________________________________________________________________________
Erickson’s Stage _______________________________________________________________________
Piaget’s Stage __________________________________________________________________________
Play Stage and Appropriate Play Items_____________________________________________________
______________________________________________________________________________________
Gordon’s Functional Health PatternsAssessment Data (Include normal and abnormal)
I. Health History/Health Perception
SUBJECTIVE OBJECTIVE
Nursing Diagnosis:
II. NUTRITION - METABOLIC
SUBJECTIVE OBJECTIVE
Nursing Diagnosis:
1
Diagnostic studies: List diagnostic studies that are ordered on this patient that relate to nutrition and metabolic, lymphatic system, integumentary system, infection, shock and cancer.
__
III. ELIMINATION
SUBJECTIVE OBJECTIVE
Nursing Diagnosis:
Diagnostic studies: List diagnostic studies that are ordered on this patient that relate to renal, genitourinary system, gastrointestinal system, liver, gallbladder, pancreas, endocrine, infection, cancer, and elimination.
IV. ACTIVITY - EXERCISE
SUBJECTIVE OBJECTIVE
Nursing Diagnosis:
Diagnostic studies: List diagnostic studies that are ordered on this patient that relate to cardiovascular, respiratory, musculoskeletal, activity tolerance and endurance, fluid and electrolytes, shock, infection, and cancer.
2
___
V. SLEEP - REST
SUBJECTIVE OBJECTIVE
Nursing Diagnosis:
Diagnostic studies:
VI. COGNITIVE - PERCEPTUAL
SUBJECTIVE OBJECTIVE
Nursing Diagnosis:
3
Diagnostic studies: List diagnostic studies that are ordered on this patient that relate to neurological, sensory, infection, cancer, and mental health.
__
VII. SELF PERCEPTION - SELF CONCEPT
SUBJECTIVE OBJECTIVE
Nursing Diagnosis:
VIII. ROLE RELATIONSHIP
SUBJECTIVE OBJECTIVE
Nursing Diagnosis:
4
IX. SEXUALITY - REPRODUCTIVE
SUBJECTIVE OBJECTIVE
Nursing Diagnosis:
Diagnostic studies:
__
X. COPING - STRESS TOLERANCE
SUBJECTIVE OBJECTIVE
Nursing Diagnosis:
XI. VALUES - BELIEFS
SUBJECTIVE OBJECTIVE
Nursing Diagnosis:
DISCHARGE NEEDS
List treatments: __
5
Special care or needs: ___
Special teaching: __
Follow up care or appointments: ___
Life expectancy: ___
Rehabilitation specify type: __
Return to: home another facility Home Health Care Long Term Care Assisted Living Final Residence
6
PATHOPHYSIOLOGY
Disease Process:
Signs & Symptoms:
Diagnostic Studies:
Medical & Surgical Treatment:
Nursing Care:
7
CLINICAL COURSE
Why was the patient admitted and what changes have occurred since this admission?
What has been the response to treatment?
8
DIAGNOSTIC STUDIES
Lab studies and x-rays ordered:
Patient results (choose at least two of the above)
Name of test:
Normal values:
Patient values:
Significance (purpose of test, nursing preparation, explain abnormal values as they relate to the patient):
Name of test:
Normal values:
Patient values:
Significance (purpose of test, nursing preparation, explain abnormal values as they relate to the patient):
9
Attach a medication information sheet including generic and trade name, classification, dosage range, route, indication and actions, contraindications, side effects, drug interactions, and nursing considerations and contraindications.
Medication Information FormMedicationGeneric & Brand Name
Dose Range Client Dose Classification Indication and Action
Side Effects/Drug interactions
Nursing Considerations and Contraindications
10
NURSING CARE AND TREATMENTS
Examples of treatments: Dressings, irrigations, incentive spirometer, breathing treatments, traction, casts, splints
11
Prioritization of nursing concerns
List all nursing concerns in order of priority.
Note: It is expected that if a problem is listed as numbers 1, 2, or 3 that these problems would be addressed in the Care Plan. At least one problem should be related to the pathophysiology, example: if the care plan is a heart patient, at least one nursing diagnosis should be related to the heart disorder.
12
(USE SEPARATE SHEET FOR EACH NURSING DIAGNOSIS)
Nursing Diagnosis: Remember to use a three part nursing diagnosis—Problem, Etiology, Symptoms
Goal: Use SMART criteria.
Actions with rationale: (Minimum of three)
Evaluation:(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Is it appropriate to keep with the original plan?)
13
(USE SEPARATE SHEET FOR EACH NURSING DIAGNOSIS)
Nursing Diagnosis: Remember to use a three part nursing diagnosis—Problem, Etiology, Symptoms
Goal: Use SMART criteria.
Actions with rationale: (Minimum of three)
Evaluation:(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Is it appropriate to keep with the original plan?)
14
(USE SEPARATE SHEET FOR EACH NURSING DIAGNOSIS)
Nursing Diagnosis: Remember to use a three part nursing diagnosis—Problem, Etiology, Symptoms
Goal: Use SMART criteria.
Actions with rationale: (Minimum of three)
Evaluation:(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Is it appropriate to keep with the original plan?)
15