KU Health & Medical Pediatrics Nursing Care Plan Worksheet

Charlie Snow is a 6-year-old Caucasian male staying with his aunt and uncle while his parents are serving overseas in the military. Charlie presents in the emergency department with tachycardia and dyspnea with mild stridor. His aunt and uncle report that he accidentally ate a cookie containing peanuts, and he has peanut allergies. When Charlie began having difficulty breathing, they rushed him to the emergency department.

He is currently able to talk through the dyspnea and is on a nasal cannula at 2 liters. A saline lock has been placed in his left arm. He has been connected to a cardiac/apnea monitor with a SpO2 probe in place. Charlie is in bed, and the healthcare provider has been notified of Charlie’s arrival.

Pharmacology: Diphenhydramine hydrochloride, Epinephrine, Methylprednisolone.

Keiser University – Miami
Pediatric Nursing
Patient Data Base
Student: ___________________________________
Date: ______________________
Directions:
1) Collect appropriate subjective and objective data utilizing patient interview,
observation, physical assessment, chart review and other data sources.
2) Highlight all abnormal findings, problems and needs.
3) Cluster all identified abnormal findings, problems and needs in each section.
4) Highlight the relevant Nursing Diagnoses for each section with possible data, risk
factors and/or abnormal findings, from the list of common diagnoses provided.
Write in any other pertinent nursing diagnoses.
5) The week before NCP due, please show work to clinical instructor for
feedback.
6) This is to be turned in once for evaluation by the clinical instructor.
Initials _______ Room Number _______ Age _____ Gender _____ Ethnicity _________
Admission Date ______________
Admitted From: Home __ ECF __ Assisted Living __ Other __ Lives with: ___________
Medical Diagnoses: _______________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Textbook Description of the Medical Dx with citations:
Etiology – What are causes for the
disease?
Client Presentation of the Disease
Pathophysiology:
Client Pathophysiology:
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Pediatric Nursing
Patient Data Base
Diagnostics – How is condition dx?
How was this Dx with your client?
Signs & Symptoms
Client presents with which s/s?
Medical and Nursing Management
Client Medical and Nursing Management
received while in hospital.
Potential Complications
Client specific Complications if any:
Reference Source: __________________________________________
Diagnostic Studies/Procedures (include date, time, indication for the test and result)
Radiology (X-rays/Scans etc) :
Procedures (biopsies, surgery):
EKG:
Consults:
Other:
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Pediatric Nursing
Patient Data Base
Laboratory Studies
Test
Hospital
Norms
Date
&
Value
Date
&
Value
Date
&
Value
1. Explain why test was ordered
for the client
2. Correlate the abnormal
findings to the client
condition
CBC
WBC
RBC M= ________
F=
HGB M= ________
F=
HCT M= ________
F=
Platelets
Differential
Neutrophils ____________
Eosinophils ____________
Basophils ____________
Lymphocytes ____________
Monocytes ____________
Electrolytes
Na ____________
K ____________
Cl ____________
CO2 ____________
Ca ____________
P ____________
Blood Glucose
Blood draw ____________
Fingerstick ____________
A1C ____________
Metabolites
BUN ____________
Creatinine ____________
Ammonia ____________
Lipid Profile
Cholesterol ____________
HDL ____________
LDL ____________
HDL:ratio ____________
Triglycerides ____________
LFT’s
SGOT/AST ____________
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Pediatric Nursing
Patient Data Base
SGPT/ALT
Alk Phos(ALP)
Total Bilirubin
Direct Bilirubin
ABG
pH
PaO2
PaCO2
O2 Saturation
HCO3
Base Excess
Other labs
Total Protein
Prealbumin
Albumin
CPK
CPK-MB
BNP
Uric Acid
Lactate (LDH)
Amylase
Blood Cultures
Aerobic
Anaerobic
Urinalysis
pH
Specific Gravity
Protein
Glucose
Ketones
Nitrites
Leuk esterase
Crystals
Casts
WBCs
RBCs
Urine Culture
____________
____________
____________
Blood Clotting
Studies
PT
PTT
INR
Hospital
Norm
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
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Therapeutic Date &
Goal
Time
Date &
Time
Date &
Time
Explain
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Pediatric Nursing
Patient Data Base
Drug Levels
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Pediatric Nursing
Patient Data Base
MEDICATIONS CURRENTLY PRESCRIBED including IV solutions
Generic &
Dose, safe
Rx Classification &
Most common &
(Brand) name
range, rate,
mechanism of action
serious side effects
frequency route
Insulin/Type
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Dose
Onset
Peak
Nursing
implications
Why was your
client prescribed
this medication?
Duration
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Keiser University – Miami
NUR 2310C Pediatric Nursing
NURSING CARE PLAN
HEALTH PERCEPTION – HEALTH MANAGEMENT ASSESSMENT
Reason for seeking health care/chief complaint:
How was the illness treated at home (include alternative/complementary therapies):
Past Medical History (date):
Past Surgical History (date):
ALLERGIES: ______________________________________________
Code Status:____________________________________________
Advanced Directives: _______________________________________
Medical Durable Power of Attorney: _________________________________
Life Style Risk Factors:_________________
________________________________________________________________________
Familial Risk Factors: (Indicate Relationship)
Diabetes ___________________ Heart Disease/HTN ____________________________
Stroke _____________________ Kidney Disease _______________________________
Mental Illness _______________ Cancer (type) _________________________________
Communicable disease ________ Other _______________________________________
=MEDICATION TAKEN AT HOME (Rx, OTC, herbal, vitamins etc)
Name of drug/dose/schedule
Client statement of drug purpose
Cluster Significant Data:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Possible Nursing Diagnoses: Risk for Injury; Risk for Infection; Deficient Knowledge;
Ineffective Health Maintenance; Ineffective Management of Therapeutic Regimen;
Health Seeking Behaviors; Other: ____________________________________________
NUTRITION – METABOLIC ASSESSMENT
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NUR 2310C Pediatric Nursing
NURSING CARE PLAN
Height ____________ Weight _______________ Body Mass Index _________________
Recent Increase: ___ (amt/time) __________ Decrease: ___ (amt/time) _____________
Obese __ (explain) ________________ Undernourished __ (explain) ________________
Type of Diet Ordered: Date:
Date:
Typical intake at home,
% eaten
% eaten
Prescribed home diet
Breakfast
Lunch
Dinner
Snacks
Problems eating/digestion food: difficulty swallowing __ nausea __ vomiting __
Abdominal pain __ antacid use __ other: _________________________________
Dentition: Condition _____________________________ Dentures: upper __ lower __
Oral Mucosa: Intact __ Pink __ Moist __ Dry __ Lesions __ Other _________________
Appetite: normal __ increased __ decreased __ Taste sensation: normal __ impaired __
Explain: ________________________________________________________________
Home Blood Glucose Monitoring: no __ yes __
Tube Feeding: __ Type of feeding ml/hr ______________ Residuals (time/amt) ______
Type of Feeding Tube: NG __ PEG __ PEJ __ Other ____________________________
Total Parenteral Nutrition: __ Rate of TPN _______________
Type of IV access: peripheral __ PICC __ Central Line __ Port __ Other ____________
Site & Appearance of Site: ________________________________________________
INTAKE
OUTPUT
PO
Urine
Tube feed
NG/Drain
IV
Emesis
Other
Stool
Other
Other
Total
Total
Drains: Type/site(s) _______________________________ Color: _________________
Nails: color ___________ shape __________ condition __________ other ___________
General skin color/texture: ________________________________________________
Skin: warm __ cool __ dry __ diaphoretic/clammy __ intact __ other ________________
Edema: no __ yes __ Grading (0-4+), site, explain ______________________________
_______________________________________________________________________
Skin Turgor: no tenting/supple __ delayed return/tents __ Site: ____________________
BRADEN SCALE (Circle the appropriate number and calculate the total score)
Sensory/percept
Complete limited 1
Very limited 2
Slight limited 3
Not impaired 4
Moisture
Constant moist 1
Very moist 2
Occ. moist 3
Rare moist 4
Activity
Bedfast 1
Chairfast 2
Occ. walk 3
Freq walk 4
Mobility
Immobile 1
Very limited 2
Slight limited 3
No Limits 4
Nutrition
Very poor 1
Inadequate 2
Adequate 3
Excellent 4
Friction/shear
Problem 1
Potential Prob 2
No Problem 3
Total
TOTAL BRADEN SCORE LESS THAN 16 INDICATES RISK OF PRESSURE ULCER!!!
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NUR 2310C Pediatric Nursing
NURSING CARE PLAN
Identify and Describe any skin lesions on the figure:
Cluster Significant Data:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Possible Nursing Diagnoses: Risk/Deficient Fluid Volume; Excess Fluid Volume;
Risk/Imbalanced Fluid Volume; Nausea; Risk/Nutrition Imbalanced: More than Body
Requirements; Risk/Nutrition Imbalanced: Less than Body Requirements; Impaired
Swallowing; Impaired Dentition; Impaired Oral Mucous Membranes; Impaired Tissue
Integrity; Risk/Impaired Skin Integrity; Risk/Infection: Other: _____________________
GI/GU ASSESSMENT
Label in the abdominal quadrants:
1) Ostomy 2) Bowel Sounds: (++)hyperactive; (+)normal; (h)hypoactive; (-)absent
Abdomen: soft __ semi soft __ firm __ distended __ flat __ tender _________________
Usual Bowel Habits: normal pattern/frequency _____________ Last BM: __________
Bowel Elimination: no problem __ diarrhea __ constipation __ incontinent __ other ___
Stool: Color ____________ Consistency ______________ Amount ________________
Ostomy: Colostomy __ Ileostomy __ Urostomy __ Describe: _____________________
Rectum: no problem __ rash __ lesion __ hemorrhoids __ other ___________________
Bladder Function: no problem __ continent __ incontinent __ urgency __ frequency __
Dribbling __ pain __ Foley catheter __ suprapubic catheter __ urostomy __ briefs __
Voiding schedule: no __ yes __ other _________________________________________
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NUR 2310C Pediatric Nursing
NURSING CARE PLAN
Urine: clear __ yellow __ cloudy __ sediment __ bloody __ foul odor __
Bladder distention: no __ yes __ Bladder scan/straight cath amount: _____________
Anuria: no __ yes __ Explain: ______________________________________________
Dialysis: hemo __ peritoneal __ Access Site ______________ Schedule _____________
Cluster Significant Data: __________________________________________________
________________________________________________________________________
________________________________________________________________________
Possible Nursing Diagnoses: Risk/Constipation; Diarrhea; Bowel Incontinence; Total
Urinary Incontinence; Impaired Urinary Elimination; Risk/Urinary Retention; Other:
__________________________
RESPIRATORY – CARDIOVASCULAR ASSESSMENT
Vital Signs
Date/time
Temperature Pulse
Respiration Blood Pressure
O2 Sat
Apical Rhythm: regular __ irregular __ Capillary refill: < 3 seconds __ > 3 seconds __
Strength of peripheral pulses: 0=absent; 1=weak; 2=normal; 3=increased; 4=bounding;
D=doppler Site: B=brachial; R=radial; P=popliteal; F=femoral; DP=dorsal pedis;
PT=posterior tibial
Date/time
Pulse
Strength
Pulse
Strength
(R)
(R)
(L)
(L)
(R)
(R)
(L)
(L)
(R)
(R)
(L)
(L)
(R)
(R)
(L)
(L)
Supplemental Oxygen: no __ yes __ nasal cannula (L/min) ______
Mask (type & %)_____
Current tobacco use: no __ yes __ type _______ pk/day ___ Desire/motivation to
quit: no __ yes __
History of tobacco use: no __ yes __ type _______ years used ___ quit date _____
Respiratory effort: even/regular __ unlabored __ labored __ accessory muscle use __
Respiratory depth: shallow __ normal __ deep __
Difficulty breathing: no __ yes __ at rest __ with exertion __ lying flat __
Cough: no __ yes __ nonproductive __ productive __ sputum color __________ sputum
consistency ___________ sputum amount ___________
Suctioning: no __ yes __ type _____ color/ amount/ frequency ____________________
Artificial Airway: no __ yes__ type ________ size/appearance ____________________
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NUR 2310C Pediatric Nursing
NURSING CARE PLAN
Chest Tube: right __ left __ drainage color/amount ______________________________
To suction: no __ yes__
Incentive Spirometer: level achieved ____________ how often used _______________
Breath sounds: Document location
Cl=clear; D=diminished; Cr-crackles; R=rhonchi; W=wheeze; A=absent
Cluster Significant Data: __________________________________________________
_______________________________________________________________________
________________________________________________________________________
Possible Nursing Diagnoses: Impaired Airway Clearance; Ineffective Breathing Pattern;
Ineffective Tissue Perfusion; Impaired Gas Exchange; Decreased Cardiac Output; Other
__________________________________
ACTIVITY – MUSCULOSKELETAL ASSESSMENT
Activities of Daily Living/Self Care Ability: 0=independent/requires no assistance;
1=requires use of an assistive device; 2 requires one person assistance; 3=requires one
person assistance and an assistive device; 4=requires two person assistance, dependent
Score
Score
Score
Eating/drinking
Bathing
Dressing
Toileting
Bed Mobility
Transferring
Ambulating
Response to Activities of Daily Living: no difficulty __ fatigue __ dyspnea __
Other __________________________________________________________________
Gait: steady __ unsteady __ posture _____________ other________________________
Upper Extremities: Strength: equal __ unequal __ strong __ moderate __ weak __
ROM: full __ limited __ explain _______________________________________
Lower Extremities: Strength: equal __ unequal __ strong __ moderate __ weak __
ROM: full __ limited __ explain _______________________________________
Assistive Devices Used: walker __ cane __ wheelchair __ crutches __ prosthesis __
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NUR 2310C Pediatric Nursing
NURSING CARE PLAN
Other___________________________________________________________________
Participates in Physical Therapy: no __ yes __ describe _________________________
History of Falls: no __ yes __ explain ________________________________________
Cluster Significant Data __________________________________________________
________________________________________________________________________
________________________________________________________________________
Possible Nursing Diagnoses: Risk/Activity Intolerance; Fatigue; Impaired Physical
Mobility; Self Care Deficit: bathing/hygiene, dressing/grooming, feeding, toileting; Risk
for Falls; Other ___________________________________________________________
SLEEP ASSESSMENT
Typical home sleep pattern: ____________ hrs/night
Naps ____________hrs/day
Typical hospital sleep pattern: __________ hrs/night
Naps ___________ hrs/day
Sleep difficulties: insomnia __ sleep apnea __ sleep aids ___________ other _________
Cluster Significant Data: __________________________________________________
_______________________________________________________________________
Possible Nursing Diagnoses: Risk/Sleep Pattern Disturbance; Other ________________
________________________________________________________________________
REPRODUCTIVE ASSESSMENT
Verbalized impact of illness, meds and treatment on sexuality: no __ yes __ explain:
________________________________________________________________________
Breasts: WNL __ variation ________________________________________________
Genitalia: WNL __ discharge __ lesions __ bleeding __ explain ___________________
History of STD’s: no __ yes __ explain ______________ Sexually active: no __ yes __
Contraceptive use: no__ yes__ type _________ Pregnant: no__ yes__ LMP ________
Screening exams: Last PAP& mammogram ________ self breast exams: no__ yes__
Last prostate exam & result _______ self testicular exam: no__ yes__
Cluster Significant Data: __________________________________________________
_______________________________________________________________________
Possible Nursing Diagnoses: Sexual Dysfunction; Ineffective Sexuality Patterns;
Ineffective Health Maintenance; Other ________________________________________
NEURO-SENSORY PERCEPTION ASSESSMENT
Primary Language:____________________________________
Mental Status: Orientation: person __ place __ time __
Level of Consciousness: alert __ drowsy/lethargic__ difficult to arouse __ unconscious _
Memory: intact __ recent memory deficit __ remote memory deficit __
Thought Process: answers questions appropriately __ Confused__
answers unreliably/poor historian __ ability to comprehend directions yes __ no__
explain:_________________________________________________________________
Restraints: indication for use ________________________ type___________________
Restraint Alternatives: bed alarm__ sitter__ frequent observation__ side rails__
Other___________________________________________________________________
Verbalized understanding of illness/treatments: no__ yes__
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NUR 2310C Pediatric Nursing
NURSING CARE PLAN
Identified barriers to learning:_____________________________________________
_______________________________________________________________________
Pupils: PERRLA yes__ no__ pupil size R___ L___
explain_________________________________________________________________
Vision: normal__ glasses__ contacts__ explain__________________________________
Hearing: normal__ impaired__ aid used: R__ L__ explain________________________
Speech: clear__ slurred__ aphasia__ nonverbal__ other___________________________
Peripheral sensory perception: heat/cold intolerance__ numbness/tingling__
Explain_________________________________________________________________
Pain: no__ yes__ location______________________ longer than 6 months no__ yes__
Aggravating factors: _________________ Alleviating factors: ___________________
Desired Pain Score: (0-10) ____________
Pain Assessment/Management: See codes below to complete the pain assessment
Date/
Time
Pain score (0-10)
Pain Quality
Pharmacologic treatment
Non-pharmacologic treatment
Side effects
Other pain indicators
CODES
Quality
Pharmacologic
treatments
Nonpharmacologic
treatments
1. PCA
2. epidural
3. IV NSAID
4. IV opiate
5. PO NSAID
6. PO opiate
7. IM/SQ med
8. other
Meds Used:
1. massage
2. distraction
3. music
4. positioning
5. heat
6. cold
7. other
____________
1. aching
2. burning
3. cramping
4. sharp
5. shooting
6. dull
7. spasm
8. throbbing
9. other
___________
Side effects
1.
2.
3.
4.
sedation
constipation
hypotension
nausea &
vomiting
5. itching
6. urinary
retention
7. numbness &
tingling
8. none
9. other
____________
Other pain
indicators
1.
facial
grimacing
2. tearful
3. moaning,
crying
4. rigid posture
5. guarding
6. restlessless
7. withdrawn
8. elevated
vital signs
9. other
___________
Cluster Significant Data: __________________________________________________
________________________________________________________________________
________________________________________________________________________
Possible Nursing Diagnoses: Confusion, Acute; Confusion, Chronic; Impaired Memory;
Acute Pain; Chronic Pain; Disturbed Sensory Perception; Disturbed Thought Processes,
Other: __________________________________________________________________
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NUR 2310C Pediatric Nursing
NURSING CARE PLAN
PSYCHOSOCIAL ASSESSMENT
Retired or Current Occupation:____________________________________________
Marital Status: married__ widowed__ divorced__ single__ life partner__
Identified support system/individuals: _______________________________________
Identification with a particular cultural group: no__ yes__ explain_______________
Cultural indicators: ______________________________________________________
Socialization: receives phone calls__ visitors__ cards__ other______________________
Major losses or life changes: no__ yes__ explain_______________________________
Changes in life roles/relationships: _________________________________________
Emotional/behavioral state: calm__ happy__ sad__ depressed__ agitated__
combative__ angry__ anxious__ other________________________________________
Verbalized fear of violence: no__ yes__ explain________________________________
Home use of drugs or alcohol for coping: no__ yes__ explain_____________________
Behaviors/statements indicating adjustment (or impaired) to stressors/illness: _____
________________________________________________________________________
________________________________________________________________________
Interest in alternative coping strategies: no__ yes__ explain_____________________
Verbalization of what is most valued in life: __________________________________
Verbalization of self as spiritual or religious: no__ yes__ explain_________________
Request for spiritual support while hospitalized: no__ yes__
Prayer__ visit from chaplain__ communion__ other______________________________
Cluster Significant Data: __________________________________________________
________________________________________________________________________
Possible Nursing Diagnoses: Grieving; Risk/Loneliness; Ineffective Role Performance;
Impaired Social Interaction; Social Isolation; Impaired Adjustment; Ineffective Coping;
Ineffective denial; Hopelessness; Risk Powerlessness; Risk/Spiritual Distress; Readiness
for Enhanced Spiritual Well Being; Other: _____________________________________
FUTURE HEALTHCARE NEEDS/DISCHARGE PLANS
Nurse anticipated future healthcare plans: home__ ECF__ live with relative__
rehabilitation__ sub-acute nursing facility__ hospice care__ home care__
Other:__________________________________________________________________
Nursing/nurses aide: ______________________________________________________
Dietary/nutrition:_________________________________________________________
Equipment/medication:_____________________________________________________
Medical follow-up:________________________________________________________
Specific Discharge Instructions:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Keiser University – Miami
NUR 2310C Pediatric Nursing
NURSING CARE PLAN
NURSING CARE PLAN (NCP) DIRECTIONS:
1) Develop a comprehensive NCP on any of the assigned clients. The NCP must be reviewed by
clinical instructor prior to final NCP. (One week prior to due date)
a) THERE IS NO SECOND CHANCES. THE STUDENT MUST ACHIEVE A 76% OR
HIGHER TO PASS THIS ASSIGNMENT. This assignment is a Pass or Fail, and the student
must pass this assignment in order to pass clinical. And the student must pass clinical in
order to pass Pediatrics 2310-C.
2) Formulate a NCP using Three (3) nursing diagnoses:
a) Only one may be “at Risk for”.
b) Write full nursing diagnoses statements.
c) Example: Ineffective airway clearance R/T increased sputum production as evidenced by
ineffective cough and coarse rhonchi.
d) Note: if nursing diagnosis is “Risk for” there is no evidence to report.
e) Prioritize using client’s level on Erikson/Maslow’s Hierarchy.
f) MAY NOT USE MEDICAL DIAGNOSIS IN YOUR NURSING DIAGNOSIS
3) Outcomes:
a) Include Nursing Outcome Classification (NOC).
b) State (2) STGs and (1) LTG.
c) Goals must be client-centered, specific, measurable, realistic, and have a time frame for
achievement.
i)
Examples: STG: Lungs will be clear in 8 hours. LTG: Client will demonstrate colostomy
care by time of discharge.
ii) STG should be during hospitalization, and LTG should be before discharge, however,
sometimes it is more appropriate for LTGs to extend beyond discharge.
4) Interventions:
a) Include Nursing Intervention Classification (NIC).
b) Prioritize interventions in order of performance.
c) Must be individualized/specific/with frequencies/and be directly related to goals.
d) Include something with teaching here
e) Cite work for all interventions
i) Example: 1. Observe/assess resp status for rate, depth, and chest wall movement Q4 hrs and
PRN (Lemone & Burke, 2004)
5) Rationales: Specific to each intervention listed and scientific.
a) Cite your work here
i) Example: 1. Tachypnea, shallow resp, and asymmetric chest movement may be indicative of
resp compromise (Lemone & Burke, 2004).
ii) Use nursing textbooks and scholarly journals only.
iii) health-related internet web sites are to be used. NO WIKIPEDIA!
6) Documentation:
a) Document your interventions as you would in written nurse’s notes. Example: 0800 RR shallow
at 24/min, even, non-labored.
7) Evaluation:
a) Evaluate each STG as met, partially met, or not met: explain why it was met, partially met, or not
met.
b) Care plan status must be discontinued, continue, or revised: as the status of the care plan.
c) Example: Goal not met. Pt was unable to verbalized understanding of instructions. Revise care
plan.
d) Note for teaching care plan:
i) In order for learning to have taken place, the client must verbalize or demonstrate something.
ii) Example: Verbalized how to read labels on canned goods for sodium content.
8) Last page of NCP must include APA formatted reference page for all works cited in interventions and
rationales.
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NUR 2310C Pediatric Nursing
NURSING CARE PLAN
Analysis of Client’s Assessment Data: Formation of Nursing Diagnoses. List down according to priority
all identified nursing problems. Formulate your NCP on the 1 st 2 nursing problems.
Based on the data base, identify objective and subjective data that may lead to actual and potential nursing
diagnoses.
Nursing Diagnosis #1
Objective Data:
Subjective Data:
Nursing Diagnosis #2
Objective Data:
Subjective Data:
Nursing Diagnosis #3
Objective Data:
Subjective Data:
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Keiser University – Miami
NUR 2310C Pediatric Nursing
NURSING CARE PLAN
Nursing Diagnosis Statement: ________________________________________________________________ Priority: _________
Nursing assessment
focused on nursing
diagnosis
OUTCOMES
INTERVENTIONS
NOC:
Client will
NIC:
Nurse will
S.T. Goals:
1.
Number at least 3 per ST
goal. Include assessment,
treatment and teaching
RATIONALES
DOCUMENTATION
“Why” of the
intervention
Data:
Number to correlate with
interventions
EVALUATION
Of short term goals:
met/not met/ partially
met; continue, revise or
discontinue. Correlate
numerically with each ST
goal.
Action:
2.
Response:
L.T. Goal:
Erikson/Maslow’s
Hierarchy Level:
Signature: ___________
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NUR 2310C Pediatric Nursing
NURSING CARE PLAN
Nursing Diagnosis Statement: __________________________________________________________________ Priority: _______
Nursing assessment
focused on nursing
diagnosis
OUTCOMES
NOC:
Client will:
INTERVENTIONS
NIC:
RATIONALES
DOCUMENTATION
“Why” of the
intervention
Data:
Nurse will:
S.T. Goals:
1.
Number at least 3 per ST
goal. Include assessment,
treatment and teaching
Number to correlate with
interventions
EVALUATION
Of short term goals:
met/not met/ partially
met; continue, revise or
discontinue. Correlate
numerically with each ST
goal.
Action:
2.
Response:
L.T. Goal:
Erikson/Maslow’s
Hierarchy Level:
Signature: ___________
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Keiser University – Miami
NUR 2310C Pediatric Nursing
NURSING CARE PLAN
Nursing Diagnosis Statement: __________________________________________________________________ Priority: _______
Nursing assessment
focused on nursing
diagnosis
OUTCOMES
NOC:
Client will:
INTERVENTIONS
NIC:
RATIONALES
DOCUMENTATION
“Why” of the
intervention
Data:
Nurse will:
S.T. Goals:
1.
Number at least 3 per ST
goal. Include assessment,
treatment and teaching
Number to correlate with
interventions
EVALUATION
Of short term goals:
met/not met/ partially
met; continue, revise or
discontinue. Correlate
numerically with each ST
goal.
Action:
2.
Response:
L.T. Goal:
Erikson/Maslow’s
Hierarchy Level:
Signature: ___________
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NUR 2310C Pediatric Nursing
NURSING CARE PLAN
References APA 6th Ed.
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CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
Anaphylaxis is an acute clinical syndrome resulting from interacting with an allergen and a patient who is
hypersensitive to that allergen. When the antigen enters the circulatory system, a generalized reaction rapidly
takes place. Vasoactive amines (principally histamine or a histamine-like substance) are released and cause
vasodilation, bronchoconstriction, and increased capillary permeability. Severe reactions are immediate
onset; are often life-threatening; and frequently involve multiple systems, primarily the cardiovascular,
respiratory, gastrointestinal, and integumentary systems. Exposure to the antigen can be by ingestion,
inhalation, skin contact, or injection. Examples of common allergens associated with anaphylaxis include drugs
(e.g. antibiotics, chemotherapeutic agents, radiologic contrast media), latex, food, venom from bees or
snakes, and biological agents (antisera, enzymes, hormones, and blood products).
DIAGNOSTIC TESTS
(REASON FOR TEST AND RESULTS)
Allergy Blood Test to measure the
amount of tryptase that can be
elevated up to three hours after
anaphylaxis
Allergy Blood Test to identify the
allergen trigger
e.g. IgE test, ELISA test, RAST test)
Allergy Skin Test
PATIENT INFORMATION
Patient: Charlie Snow
Gender: Male
DOB: 5/5/2014
Allergies: Peanuts, perfumes,
and dyes
Immunizations: Up to date
Adm Dx: Anaphylaxis
Adm On: 4/5/2021
ANTICIPATED PHYSICAL
FINDINGS
The onset of clinical symptoms
usually occurs within seconds or
minutes of exposure to antigen. The
sooner the onset, the more severe
the reaction. S&S: uneasiness,
restlessness, irritability, severe
anxiety, headache, dizziness,
paresthesia, disorientation, LOC,
flushing, urticaria, angioedema,
bronchiolar constriction,
pulmonary edema and hemorrhage,
laryngeal edema, shock
ANTICIPATED NURSING INTERVENTIONS
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Obtain a thorough health hx of a child from caregiver and child, including previous reactions to allergies and what the
patient is or may be allergic to
Document and chart all known allergies (e.g., food, medications, environment, etc. and obtain allergy bracelets for a child to
wear.
Encourage the child to talk about fears and concerns
Provide support and guidance to the child and family
Full set of vitals: Temp, HR, RR, BP, Pulse ox, Pain
Respiratory Assessment, e.g. Breath sounds, assessment for cyanosis
Cardiac Assessment: e.g., all peripheral pulses, HR, BP
Assess for dehydration, e.g. Capillary refill, Skin Assessment
Further allergic reactions, e.g. Swelling, Hives
After 2nd contact with the provider:
Monitor VS q 5 min
Administer NS, epinephrine, diphenhydramine, ranitidine, and methylprednisolone as prescribed. Administer O2 as
prescribed to keep O2 sat >94% via NC or non-rebreather
HOB elevated
Continuously monitor saturations and keep an eye on RR, as this can be affected by swelling of the throat
Recheck BP frequently
Give fluids that will assist in maintaining BP if needed. Quick, direct rapid administration of medications required
vSim ISBAR ACTIVITY
INTRODUCTION
STUDENT WORKSHEET
Elizabeth Martin RN Pediatric Department
Your name, position (RN), unit you are
working on
SITUATION
Charlie Snow is a 6yo male child brought to the ED at 1500 for sudden
onset dyspnea.
Patient’s name, age, specific reason for visit
BACKGROUND
Patient’s primary diagnosis, date of
admission, current orders for patient
ASSESSMENT
Current pertinent assessment data using headto-toe approach, pertinent diagnostics, vital
signs
RECOMMENDATION
Any orders or recommendations you mayhave
for this patient
He presented with an onset of severe dyspnea 30 minutes ago by his
aunt, who states he has a peanut allergy and the symptoms began
shortly after he had eaten a new brand of cookie. Currently, he is on
orders for supportive oxygen via nasal cannula or non-rebreather mask
to maintain SpO2 >94%.
On assessment patients, pain rated 0 on FACES. The patient stated he
could not breathe and felt like his throat was swelling. The patient’s
SpO2 was 90%. His breath sounds were equal with stridor and
prolonged expiration. The patient’s airway appears clear with no
visible obstruction. Patients vitals are BP 86/54, 99*F, SpO2 90%, HR
145
I would like to continue with the oxygen as ordered on a nonrebreather. I would recommend starting medications for the treatment
of anaphylaxis, including epinephrine, an antihistamine, a steroid, and
also an infusion of IV fluids to bring his blood pressure up and
maintain perfusion
PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: Methylprednisone 10mg IV
CLASSIFICATION: Corticosteroid, anti-inflammatory agent
PROTOTYPE: Cortisone
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
IV: children 94% or BP resulting in poor
oxygenation and perfusion
Patient shows signs of exhaustion from labored breathing
What Assessments will focus on for this patient?
(How will I identify the above signs &Symptoms?)
1.
2.
3.
Frequent assessment of airway
Assessment of vitals including SpO2, BP, HR and temperature
Assess for patient use of accessory muscle use with breathing
Management of Care: What needs to be done for this Patient Today?
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2.
3.
4.
5.
6.
Monitoring of vital signs
Monitoring of airway
Administration of medications
Fluid administration to increase blood volume
Administration of oxygen
Frequent re-assessment of the patient for symptoms of anaphylaxis, respiratory
distress, or hypovolemic shock
Priorities for Managing the Patient’s Care Today
1. Administer medications
2. Monitor the patient for signs and symptoms of anaphylaxis
3. Provide oxygen therapy as needed
4. Educate the patient on avoiding allergens and proper use of epinephrine autoinjector.
List Complications may occur related to dx, procedure, comorbidities:
1.
2.
3.
4.
Respiratory failure
Laryngeal edema
Syncope
hypoxic organ damage
What nursing or medical interventions may prevent the above Alert or complications?
1. Increase in fluids to increase blood volume
2. Frequent vital assessment and assessment of the face, neck and airway.
3. Monitoring patients vitals regularly per prescriber orders to determine problems
early.
4. Administration of medication quickly to counteract anaphylaxis and continued
monitoring of symptoms to catch return or worsening symptoms early.
What aspects of the patient care can be Delegated and who can do it?
UAP can perform vitals assessments if allowed by the facility, help with feedings and hygiene
tasks, assist in toileting, assist in ambulation as prescribed.