PEDIATRIC CARE PLAN

  PATIENT INFORMATION: PT Initial: ___ Age ___ Gender ___ Race/Ethnicity __________ Primary Language __________ Religious Affiliation __________ Date of Admission: ________ Admit Reason/Symptoms: _________________________________________¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬-_________________________________________ Current Medical Diagnosis: __________________________________________________________________________________________________________________ Current surgeries or procedures (Planned or performed with date): ___________________________________________________________________ Past Medical History (Resolved Medical Diagnoses/Illnesses/Surgeries, give date): __________________________________________________ Family (Genetic) History of Diseases: ______________________________________________________________________________________________________ Educational Level: _______________ Living Arrangement: ___________________________________________________________________________________ Discharge Plan and educational needs (Parent/Child): ___________________________________________________________________________________ Allergies & Reaction: _________________________________________________________________________________________________________________________ Precautions (circle) confusion, suicide, paralysis, infant or toddler, fall risk, other: ___________________________________________________ Advance Directives (Do Not Resuscitate/Other): Yes _____ No _____ Comments: ________________________________________________________   DAY OF CARE: All current MD orders for day of care: ______________________________________________________________________________________________________ Respiratory Care: ____________________________________________________________________________________________________________________________ Dietary Orders: _______________________________________________________________________________________________________________________________ Diagnostic studies treatment for day of care (x-ray, ultrasound, CT, etc.): ______________________________________________________________ Prioritize activities for nursing care for your shift (respiratory care, vital signs, feeding, hygiene, meds, assessment, therapy, education, play, ect.) 1. 4. 2. 5. 3. 6. PATHOPHYSIOLOGY: Provide a definition of TWO problems: pathophysiology, etiology, epidemiology. Include signs and symptoms of the disease, relevant laboratory studies with indication of values if high or low (blood, or other body fluid tests); diagnostic studies (x-rays, ultrasound, electrocardiograms, etc). Identify the interventions (surgical procedures, interventional procedures, types of medications, etc.) used to treat/cure this disease or illness. Describe the complications that can develop from this disease/illness. List specific nursing interventions provided to treat this disease/illness or to prevent complications from this disease/illness. Identify whether this is an ACUTE ILLNESS; CHRONIC; TERMINAL. *All may not apply to your patient. Highlight what specifically applies to your patient.* 1. 2. APA References: Develop a comprehensive list of expected developmental milestones for a child who is your patient’s age. Then list developmental milestones your patient has achieved. Patient’s Age______ Expected Developmental Milestones My Patient’s Milestones Cognitive: Social: Physical: Gross/fine motor:   Discuss the expected developmental level according to the following theorists. Then discuss where your patient Patient’s Age ______ Expected Actual Erikson (psychological) Piaget (cognitvie) Freud (psychosexual)   APA References: Prioritize top 6 Nursing Diagnoses (List must include a minimum of one wellness diagnosis.) Nursing Diagnosis Rationale for Selection 1. 2. 3. 4. 5. 6.                   Plan of Care with NANDA, NOC and NIC Priority from Nursing Diagnosis Prioritization and NANDA Diagnostic Statement Nursing Outcome Desired During Your Shift (NOC) Nursing Activities: List 3, at least one must be hands on. List who will perform. (NIC) Rationale for Each of Your Nursing Activities. Use References. Based on NOC Outcome Criteria, Evaluate Nsg Activities. Goals If not met, what will you change? Priority #1:   NANDA Statement:   NOC Outcome:   Patient Goals:   Measurement Criteria: NIC:   1.   2.   3.     Rationales:   1.   2.   3.   APA References: Goal was: (circle one) Met Not Met Partially Met (explain): Evaluation of Nursing Activities:   Based on measurement criteria: What was happening with your patient?   What will you change? (priority, goal, activities) Priority from Nursing Diagnosis Prioritization, and NANDA Diagnostic Statement Nursing Outcome Desired During Your Shift (NOC) Nursing Activities: List 3, at least one must be hands on. List who will perform. (NIC) Rationale for Each of Your Nursing Activities. Use References. Based on NOC Outcome Criteria, Evaluate Nsg Activities. Goals If not met, what will you change? Priority #2:       NANDA Statement: NOC Outcome:   Patient Goals:   Measurement Criteria: NIC:   1.   2.   3. Rationales:   1.   2.   3. APA References: Goal was: (circle one) Met Not Met Partially Met (explain): Evaluation of Nursing Activities:   Based on measurement criteria: What was happening with your patient?