PEDIATRIC CARE PLAN

Patient Data Base

Student__________________________________Instructor__________________________________
No Section is to be left blank without explanation.

ASSESSMENT OF HEALTH PATTERNS

Patient’s Initials
Date of Assessment
Age
Date of Birth
Sex
Race

Source of Information
Reason for Admission
Today’s Chief Concern
(Patient, Parent, Nurse)
Present Diagnosis
Present 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 Oximetry
Height 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 Tim
e
Memory Short Term Long Term

Speech Clear Slurred or Stuttered

Allergies Food Medication Seasonal Type of reaction

Vision (Include How tested) Normal Impaired Glasses Contacts

Reading or
Long-distance
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
Child’s Use of Alcohol Street Drugs/Glue Tobacco

Family History of Diabetes Heart Disease or Hypertension Kidney

(include relationship) Malformations 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
Other
Unable 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
Flatus
Bowel Sounds( 4 Quadrants)
Abdomen Soft Distended
Presence of History of Incontinence Pain Burning
(give Dates)
Frequency Retention Difficulty Voiding
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 Sensation

Presence or History of Hypertension Ankle/Leg/ Pitting/Nonpitting Slow

(Give Dates) Sacral/Periorbital Edema Healing
Edema
Chronic wounds Heart Trouble Phlebitis Other

Breath Sounds
Dyspnea
Cough/Sputum (Frequency/Color,
quantity and tenacity)
Airways Endotracheal Tracheal Ventilator
Presence or History of Bronchitis Pneumonia Orthopnea Asthma
(Give Dates)
Wheezing Respiratory Tx Exposure to Smoking
Noxious (Pks/d/m
Fumes #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 angle
limitation 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 client’s 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)

______________________________________________________________________________________
________________
Pt’s 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 CLIENT’S RATIONALE FOR THIS CLIENT’S NURSING INTERVENTIONS
VALUES RESULTS RESULTS (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 CLIENT VALUES RATIONALE FOR THIS CLIENT’S NURSING INTERVENTIONS(Pre and Post-test and some
VALUES RESULTS resulting from test results)

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 PLAN OF CARE*

DATE:____________________________________ Prioritized Nsg Dx

1.____________________________
NAME____________________________________ 2.____________________________
3.___________________________
CLIENT’S INITIALS:_____________

PATTERN NURSING MUTUALLY NURSING SCIENTIFIC EVALUATION AND

MANIFESTATION DIAGNOSIS DEVELOPED INTERVENTIONS RATIONALES AND MODIFICATION
OUTCOMES REFERENCES
NANDA Assessment(2)
STATEMENT

Actions(4)

RELATED TO

AS EVIDENCED BY Teaching(2)

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 PATTERN NURSING MUTUALLY NURSING SCIENTIFIC EVALUATION AND
MANIFESTATION DIAGNOSIS DEVELOPED INTERVENTIONS RATIONALES AND MODIFICATION
OUTCOMES REFERENCES

NANDA
STATEMENT(Cont

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