Pediatric Nursing Care Plan
Pediatric Nursing Care Plan Assignment- Walden University
Nursing care plan for a pediatric patient. Disease and age of your choice.
| Student | Date | ||||
| Instructor | Course | ||||
| Patient Initial | Unit/ Room# | DOB | |||
| Code Status | Height/Weight | ||||
| Allergies | |||||
| Temp (C/F Site) | Pulse (Site) | Respiration | Pulse Ox (O2 Sat) | Blood Pressure | Pain Scale 1-10 |
|
|
| History of Present Illness including Admission Diagnosis &
Chief Complaint (normal & abnormal) supported with Evidence Based Citations |
Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations |
|
|
| Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),
include dates and rationales supported with Evidence Based Citations
|
Past Medical & Surgical History,
Pathophysiology of medical diagnoses (include dates, if not found state so) Supported with Evidence Based Citations |
|
|
| Erikson’s Developmental Stage with Rationale
And supported by Evidence Based Citations |
Socioeconomic/Cultural/Spiritual Orientation
& Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations |
|
|
| Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each
(“At Risk for…” nursing dx) |
Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale
supported with Evidence Based Citations |
|
|
| Contributing
Factors |
| Diagnostic
Label |
|
Related to |
|
As evidenced by |
| Signs and
Symptoms |
Permalink: https://collepals.com/pediatric-nursing-care-plan/
| Priority Nursing Diagnosis
(at least 2) Written in three part statement
|
Planning
(outcome/goal) Measureable goal during your shift (at least 1 per Nursing diagnosis)
|
Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching
(at least 4 per goal) |
Rationale Each must be
supported with Evidence Based Citations |
Evaluation
Goal Met, Partially Met, or Not Met & Explanation
|
MEDICATION LIST
| Medications (with APA citations | Class/Purpose | Route | Frequency | Dose (& range)
If out of range, why? |
Mechanism of action
Onset of action |
Common side effects | Nursing considerations
specific to this patient |
STUDENT NAME: COURSE: DATE:
PATIENT INITIALS: ___________ PATIENT DISEASE/DISORDER:
| Criteria | 4
Exceeds Expectations |
3
Meets Expectations |
2
Approaching Expectations |
1–0
Does Not Meet Expectations |
Score |
| History of Present Illness | HPI explained in detail with accurate and in-depth understanding of chief complaint and supported by evidence based citations. | HPI explained in some detail with moderate understanding of chief complaint or no support from evidence based citations. | HPI explained in limited detail with marginal understanding of chief complaint and no support from evidence based citations. | HPI details limited with poor understanding of chief complaint and no evidence based citations to support. | X2 |
| Physical Assessment, & Diagnostic tests/ procedures | Identifies 5-6 key assessments parameters relevant to medical diagnoses with relevant diagnostic procedures supported by evidence based citations. | Identifies 3-4 key assessments parameters relevant to medical diagnosis with relevant diagnostic procedures supported by evidence based citations. | Identifies 1-2 key assessments parameters relevant to medical diagnosis, relevant diagnostic procedures and vaguely supported by evidence based citations. | Identifies assessments parameters not relevant to medical diagnoses, relevant diagnostic procedures or not supported by evidence based citations. | X2 |
| Past Medical &
Surgical History, Pathophysiology |
Past medical/surgical history detailed with full explanation of Pathophysiology for each diagnosis & accurate details with specific detail related to the client’s history and symptoms and supported by evidence based citations.
|
Past medical/surgical history given with partial explanation of identified preexisting medical diagnoses & explanation accurate with some detail related to the client’s history and symptoms. supported by evidence based citations. | Past medical/surgical history given with minimal explanation of identified preexisting medical diagnoses & few details related to the client’s history and symptoms or not supported by evidence based citations. | No past medical/surgical history given without explanation; no pre-existing medical diagnosis identified or explanations inaccurate and not related to the client’s history and symptoms without evidence. | X2 |
| Erikson’s
Developmental Stages
|
Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations. | Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations. | Identifies correct stage without adequate definition or example of meeting/not meeting tasks without evidence based citations. | Identifies incorrect stage without definition or inappropriate examples given, not supported by evidence based citations. | X2 |
| Socioeconomic/ Psychosocial Assessment | Describes socioeconomic and cultural background in complete detail with references; Identifies 3 psychosocial concerns. | Describes socioeconomic and cultural background in some detail with references; Identifies 2 psychosocial concerns. | Describes socioeconomic and cultural background in vague detail without references; Identifies 1 psychosocial concern. | Describes socioeconomic and cultural background
with no detail without references; Identifies no psychosocial concerns. |
X1 |
| Interprofessional
Consults & Discharge Referrals |
Lists 3 or more appropriate collaborative issues/concerns; Rationale demonstrates excellent understanding of consults and interventions. | Lists 2 appropriate collaborative issues/concerns; Rationale demonstrates satisfactory
understanding of consults and interventions. |
Lists 1 appropriate collaborative issue/concern; Rationale demonstrates vague understanding of consults and interventions. | Lists inappropriate collaborative issues/concerns; Rationale demonstrates unsatisfactory
understanding of consults and interventions. |
X2 |
| Potential Health
Deviations |
Identifies TWO prioritized risk factors in proper format; Writes 3 independent nursing interventions. | Identifies 1 prioritized risk factor in proper format; Writes 2 independent nursing interventions. | Identifies 2 prioritized risk factors but not in proper format; Writes 1 independent pertinent nursing intervention. | Does not identify prioritized risk factors; Writes 0-1 independent nursing intervention not pertinent to the diagnosis. | X3 |
| Priority
Nursing Diagnosis |
TWO (2) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis. | One (1) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis. Written correctly without sufficient data to support diagnosis. | Written incorrectly with sufficient data to support diagnosis, not a priority. | Written incorrectly, not in correct format, or without sufficient data to support diagnosis. | X4 |
| Planning/Goals &
Evaluation |
Goal is measureable, realistic, related to the problem; Data supports if goal is met, not met with appropriate revisions. | Goal is not measureable, realistic, related to the problem; Data somewhat supports if goal is met, not met with appropriate revisions. | Goal is not measureable, not realistic, related to the problem; Data vaguely supports if goal is met, not met with inappropriate revisions. | Goal is not measureable, not realistic, not related to the problem; Data does not support if goal is met, not met with inappropriate revisions. | X2 |
| Implementation and
Rationale |
Identifies 4 independent interventions with teaching; Each is supported with scientific rationale using textbook or evidence based citations. | Identifies 3 independent interventions with teaching; Scientific rationale is supported with scientific rationale using textbook or evidence based citations. | Identifies 2 independent interventions with teaching; Scientific rationale is vaguely relevant & not supported from textbook. | Identifies 1 independent interventions with teaching; Scientific rationale is not relevant & not supported from textbook. | X2 |
| Medications | Lists all MAR medications with relevant side effects and nursing considerations specific to patient and reasons why patient is receiving drug. | Lists all MAR medications but does not include relevant side effects and nursing considerations specific to patient and why patient is receiving drug. | Lists most of the MAR medications with relevant side effects and nursing considerations specific to patient and why patient is receiving drug. | Lists some MAR medications but does not include relevant side effects and nursing considerations specific to patient. | X2 |
| General Organization | Accurate APA format; Appropriate citations & references; No spelling or grammar errors. | 1-2 APA format errors; Some citations, references are appropriate; Minimal spelling or grammar errors. | Many APA format errors; Inappropriate citations or references; Many spelling or
grammar errors. |
No APA formatting; No citations or references included; Many spelling or grammar errors. | X1 |
| Total | /100 % | ||||
COMMENTS:
FACULTY SIGNATURE: DATE:
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