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What lead to your client being in Peds? (Research the cause/disease process) What treatment(s) is your client receiving?

What lead to your client being in Peds? (Research the cause/disease process) What treatment(s) is your client receiving?

Pediatric Assignment

Gender: ________________

Age: ______________ Chief complaint: _________________

Medical History:

 

 

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BP

 

   
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What lead to your client being in Peds? (Research the cause/disease process)

 

 

 

What treatment(s) is your client receiving?

 

 

 

 

What is the Erikson Stage of Development for your client? Give at least one example from your time with your client that shows their development stage. How does the stage of development impact the care given to your client?

 

 

 

 

What are some cultural consideration you noticed with your client and his/her family?

 

 

 

 

 

 

 

 

 

 

 

 

Healthcare systems elements (continued) ALLERGIES:
Medications: List all medications, dosages, classifications and the rational for the medications prescribed for this patient include major considerations for administration and the possible negative outcomes associated with this medication.

DEFINE 1: What the medications does to the body to the cellular level AND 2: Why the patient is taking the medication?

Medication/dose Classification Indication/ Rationale SE’s/Nursing Considerations Client Education Text Reference

 

 

         
 

 

         
 

 

         
           
 

 

         
 

 

         
 

 

         
 

 

         
 

 

         
 

 

         
 

 

         
 

 

         
 

 

         
 

 

         

 

 

 

 

 

 

 

 

 

 

CON CEPT MAP

Pathophysiology – (to the cellular level)

Medical Diagnosis

Pneumonia

Signs & Symptoms/Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies) (What symptoms does your client present with?)

Complications

Treatment (Medical, medications, intervention and supportive)

Causes/Risk Factors (chemical, environmental, psychological, physiological and genetic)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nursing Diagnosis

Problem statement: (NANDA)

 

Related to: (What is happening in the body to cause the issue?)

 

Manifested by: (Specific symptoms)

 

 

  LAB VALUES AND INTERPRETETION

 

   
LAB

 

 

Normal

Range

Value Clinical Significance Nursing Assessments/

Interventions Required:

LAB Normal

Range

Value Clinical Significance Nursing Assessments/

Interventions Required:

HEMATOLOGY         CHEMISTRY        
CBC         Glucose        
WBC         BUN        
RBC         Cr        
HGB         GFR        
HCT         Na        
PLATLETS         K        
Diff:         CO2        
Polys         Ca        
Bands         Phos        
Lymphs         Amlylase        
Mono’s         Lipase        
Eosin         Uric Acid        
GBC indices         Protein        
MCV         Albumin        
MCH         Cl        
MCHC         Enzymes        
COAG’S         LDH        
PT         CPK        
INR         SGOT        
PTT         SGPT        
ABG’S(V 0R A)         Triponin I        
PH         Myoglobin        
PCO2                  
PO2         Cholesterol        
BASE EX:         UA        
SAT:                  
URINALYSIS Normal

Range

Value Clinical Significance Nursing Assessments/

Interventions Required:

 

 

 

 

Findings Clinical Significance Nursing Assessments/

Interventions Required

Color         Gastroccult      
Clarity         Hemoccult      
Sp. Gravity          

 

     
pH                
Protein                
Glucose                
Ketones                
Bilirubin                
Occ. Blood         RADIOLOGY      
Urobilogen                
WBC         EKG      
RBC                
Epithelia         PET SCAN      
WBC                
RBC         CT      
Epith Cell                
Bacteria         MRI      
Hyal Cast         MRA      
Gran Cast         Ultrasounds      
Leukocytes                
Nitrite                
ACCUCHECKS         Endoscopy      
          Colonoscopy      
                 
Additional information:

 

 

 

 

 

 

 

 

 

Reflection:

 

 

 

 

 

 

 

 

 

 

REMEMBER THAT THE EXPECTED OUTCOMES MUST BE MEASURABLE. THE INTERVENTIONS ARE WHAT YOU DO TO ASSURE THE OUTCOME AND THE CLIENT’S RESPONSE IS SPECIFICALLY HER RESPONSE.

PLAN OF CARE: Use your top two priorities

NANDA NURSING DIAGNOSIS use NANDA definition Expected outcomes of care (Goals) Interventions Patient response Goal evaluation
NRS DX:

Problem Statement:

 

 

 

 

 

 

 

 

R/T: (What is the cause of the symptom)

 

 

 

 

 

 

 

 

Manifested by: (Specific symptoms)

 

 

 

 

 

 

 

 

 

Short term goal : Create a SMART goal that relates to hospital stay/shift/day.

 

 

 

 

 

 

 

 

 

 

 

 

Long term goal : Create a SMART goal that is appropriate for discharge.

 

This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)

 

Interventions for short-term goal:

1.

2.

3.

 

 

 

 

Interventions for longterm goal:

1.

2.

3.

 

 

Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)

 

 

 

Reassess for short-term goal:

1.

2.

3.

 

 

 

 

 

Reassess for long-term goal:

1.

2.

3.

 

Was it met or not met there is no partially met.
NANDA NURSING DIAGNOSIS use NANDA definition Expected outcomes of care (Goals) Interventions Patient response Goal evaluation
NRS DX:

Problem Statement:

 

 

 

 

 

 

 

 

R/T: (What is the cause of the symptom?)

 

 

 

 

 

 

 

 

 

 

Manifested by: (specific symptoms)

 

 

 

 

 

Short term goal: Create a SMART goal that relates to hospital stay.

Long term goal: Create a SMART goal that is appropriate for discharge.

 

This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)

 

 

Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch) Was it met or not met there is no partially met.

Reflection:

Please give references.

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NB

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