FLORIDA GULF COAST UNIVERSITY
FLORIDA GULF COAST UNIVERSITY
College of Health Professions
School of Nursing
17 Questions to Answer Prior to Giving Care to Any Child
1. Why is your child in the hospital? (in chart)
2. *What kind of diet is your child on?
3. If caring for an infant, *how much formula is he/she to take and when is the next feeding due? (probably ask the night nurse when the last feeding was)
4. *Are you to keep track of your child’s I&O?
5. *What are you to test your child’s urine for? Stool?
6. *Does your child need to be weighed today? If yes, when?
7. *What is the activity level ordered for your child?
8. What time will you take his/her temperature? (graphic sheet)
9. How will you take his/her temperature? (graphic sheet)
10. *What other assessments are ordered to be done? neuro? neurovascular?
11. What IV fluid is ordered? (IV sheet or plan of care) If lipids are running, when are they to end? (usually run 12-18 hours)
12. What rate is ordered for the IV? (IV sheet or plan of care)
13. What are the functions of any tubes in your child? Where do they go? How must you care for the tube, the skin, the pt?
14. *What other procedures are ordered for your child today? dressings? suctioning? chest PT? irrigations? ambulations? turning? ISB?
15. At what time are you to do the procedures?
16. What do we want to happen to this child before we can discharge him/her?
17. Why is your child receiving her meds?
*Means info will be on plan of care
FLORIDA GULF COAST UNIVERSITY
College of Health Professions
School of Nursing
Patient Care Time Management
| |6:50 |7:00 |7:30 |8:00 |8:30 |9:00 |9:30 |10:00 |10:30 |11:00 |
|check | | | | | | | | | | |
|orders | | | | | | | | | | |
|hear | | | | | | | | | | |
|report | | | | | | | | | | |
|see | | | | | | | | | | |
|instructor | | | | | | | | | | |
|take vs | | | | | | | | | | |
|assess | | | | | | | | | | |
|eat or | | | | | | | | | | |
|feed | | | | | | | | | | |
|bathe | | | | | | | | | | |
|IV | | | | | | | | | | |
|I&O | | | | | | | | | | |
|meds | | | | | | | | | | |
|change | | | | | | | | | | |
|dressing | | | | | | | | | | |
|IV | | | | | | | | | | |
|ISB | | | | | | | | | | |
|irrigate | | | | | | | | | | |
|CPT | | | | | | | | | | |
|report off | | | | | | | | | | |
|teeth/oral | | | | | | | | | | |
|hair | | | | | | | | | | |
|shave | | | | | | | | | | |
FLORIDA GULF COAST UNIVERSITY
College of Health Professions
School of Nursing
Student: ___________________ Date:___________
Guide for Clinical Preparation
In preparation for clinical experience each student will complete the following information and hand it to the
instructor at 7:00 AM on the first day of clinical experience.
Patient’s initials or first name___________ Medical Diagnosis___________________________
Age (in years & months)_______________ Surgical Procedure and Date___________________
Date of Admission____________________ Underlying Diagnoses________________________
“Normal Vital Signs for child this age: Stool tests?_____ Urine tests?_____
P______ R______ B.P.______
List IV: Dilute in what solution?: Dilution factor: Time Due: Length of infusion:
Two age appropriate play activities for this child in the hospital:
1)
2)
Two appropriate areas of health teaching on the day you care for the child:
1)
2)
I have reviewed the following nursing procedures in preparation for this clinical experience:
________________________________ _________________________________
________________________________ _________________________________
________________________________ _________________________________
Description and pathophysiology (include pertinent underlying pathophysiology):
FLORIDA GULF COAST UNIVERSITY
College of Health Professions
School of Nursing
Student: ___________________ Date:___________
Guide for Clinical Preparation (page 2)
Usual clinical manifestations including lab results (cite your child’s manifestations):
Usual treatment (cite your child’s treatment):
Usual nursing responsibilities and assessments:
Give two nursing diagnoses which would be appropriate for a child with this condition.
1.
2.
FLORIDA GULF COAST UNIVERSITY
College of Health Professions
School of Nursing
Student: ___________________ Date:___________
DEVELOPMENTAL ASSESSMENT:
ERIKSON’S DEVELOPMENTAL STAGE:_______________________ VS _______________________
|Psychosocial Development |Describe Observations |
|Pertinent developmental tasks/needs | |
|Organize in Denver II categories for children | |
|under six years of age, and in the following categories for | |
|Children over six years: | |
|1. Cognitive |Where do you place the child developmentally? |
|2. Social abilities/tasks |(At what age for each category?) |
|3. Physical growth and motor ability | |
|4. Family relationships | |
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|Write a brief summary on Erikson’s stages for all patients. |State conclusion as to whether child |
| |is on target for age by comparing |
| |with norms on left and Erikson’s |
| |Developmental Stage. |
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FLORIDA GULF COAST UNIVERSITY
College of Health Professions
School of Nursing
Student: ___________________ Date:___________
Medications Patient’s Weight ______kg
|Generic/trade names |Safe range |1. Drug Classification |Adverse Effects |Nursing responsibilities |
|Dose, route, frequency |1. Calculate safe range for 24 hrs. |How drug works | |when administering drug |
|Ordered for child. |State mg/kg guidelines. |Desired effect for patient. | | |
|Give dose in mg, |2. Calculate patient’s dose | | | |
|not cc. |for 24 hours. | | | |
|Please number drugs. | | | | |
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FLORIDA GULF COAST UNIVERSITY
College of Health Professions
School of Nursing
NURSING ASSESSMENT GUIDE*
Child’s Initials: Informant: Date:
Birth date:
I. Presenting Problem and Brief History of Present Illness:
II. Family History
Mother – health problems? occupation?
Father – health problems? occupation?
Grandparents – health status?
Siblings – health status? – ages? Grade in school?
Language spoken?
Is there a family history of:
Allergies – asthma
Anomalies (birth defects)
Heart Disease
Diabetes
Malignancies
Tuberculosis
Neurological Disorders – seizures
Mental Retardation
Bleeding Tendency
Serious Illness or Disability
*(Guidesheet is for various ages from infancy to adolescence. Use selected parts of this guide depending on the specific age of your patient). Select those areas appropriate to the child’s age.
III. Prenatal and Birth History
Mother:
Previous pregnancies
Abortions or miscarriages
Medical Supervision during this pregnancy
Illness during pregnancy
Medications
Duration of this pregnancy
Length and quality of labor
Anesthesia
Child:
Birth weight of infant
Any problems in hospital
- mother - child
IV. Child’s Health History
Accidents – Hospitalization – when? where?
Illnesses – Hospitalizations – when? where?
Medications taken at home
Allergies
Reaction to medications or immunizations
Reaction to previous hospitalizations
Parents’ attitudes toward child’s hospitalizations
V. Developmental Patterns (discuss those appropriate to Child’s age.)
Eating patterns or Feeding behavior
Any problems in nursing or feeding
Appetite
Type of feeding - formula solids
Likes
Dislikes
Vitamins – what kind, how much?
Elimination patterns
Toilet trained
Words used to indicate needs
Mother’s reaction to patient’s ability
Any problems urinating
Sleep patterns
Length of sleep
Sleeping arrangements in family
Growth patterns
Birth weight
Birth length
Dentition
Teeth – number
care
Behavior patterns
Fears
What behavior concerns the family?
Play patterns of younger children or recreational interests of adolescents?
Safety and Environmental factors
Do you ever leave the child alone?
Do you use a car seat or seatbelt?
Does he/she play in an area where there is peeling paint or plaster?
General description of home and neighborhood
VI. Review of Systems
Does the child have any history of problems since birth? This is not to be a
physical exam.
Integument – Any rashes, excessive dryness, acne?
Head – Headaches, dizziness?
Eyes – Squinting, rubbing eyes, uses glasses?
Ears – Any earaches, evidence of hearing loss?
Nose – Nosebleeds, “stuffy” nose?
Mouth, Throat – Difficulty with teething? Toothache? Last visit to dentist?
Respiratory – Colds? Chronic cough? Shortness of breath?
Cardiovascular – Any fatigue or exertion? History of heart murmurs?
Gastrointestinal – Any nausea, vomiting, diarrhea, constipation?
Genitourinary – Pain on urination? Hematuria?
Gynecologic – Menarche? Vaginal discharge?
Musculoskeletal – Muscle pains? Fracture, sprains?
Neurological – seizures? migraines? diseases of?
VII. Immunization Record
List the immunizations the infant/child has had and the age at which they were
given. (If information is not available, list the immunizations the child should
have had and the ages when they were due.)
FLORIDA GULF COAST UNIVERSITY
College of Health Professions
School of Nursing
PHYSICAL ASSESSMENT
(Guidelines for all ages – select those areas that relate to your child.)
Date: Age: T- P- R- BP-
Height- Percentile: Weight- Percentile-
General Appearance – your first impression upon seeing the child
Head – circumference – percentile
fontanels
sutures
symmetry
scalp
hair
Eyes – red reflex
iris, cornea, sclera, conjunctiva
Ears – external canal
tympanic membrane
location in relationship to the eyes
Nose – patency, drainage
Mouth – palate
tongue movements
teeth – number, condition
mucous membranes
Pharynx – tonsils
Neck – motion
lymph nodes
Chest – configuration
Lungs – sounds
respiratory rate
Heart – sounds
rhythms
rate
Breasts – tissue
adolescents – Tanner’s Stage
Abdomen – bowel sounds
masses
femoral pulses
tenderness
distended; soft
Genitalia – testes descended
circumcised
urinary stream
vaginal discharge
adolescents – Tanner’s Stage
Anus – patent
Hips – abduction
Extremities – range of motion of each joint
muscle tone
clubbing
cyanosis
edema
Spine – staight
dimples
Skin – color
turgor
eruptions
incisions
suture/dressings
capillary refill
Nutrition – 24 degrees Intake & Output (see CALORIE COUNT SHEET)
dietary changes noted
weight trend: admission wt__________ today’s wt__________
Neurological – LOC
orientation
Infantile Reflexes Toddler (12-36mo.)reflexes
tonic neck motor activity (gross & fine)
moro crawling
dancing walking
rooting drawing
sucking language ability*
palmar grasp verbal ability
plantar grasp follow object – gaze
auditory response
Deep tendon reflexes – over three years
Do not use “normal” in recording – describe your findings. Please be sure to include Ivs, G-tubes, incisions, chest tubes, Foleys, drains, dressings, etc.
Summary of Laboratory Tests/Diagnostic Data and Relevance to Patient
(If patient has no labs state normal values for age.)
|Lab/Diagnostic Test |Client’s Values |Reasons for Client’s |Nursing Assessment |Nursing Interventions |
|Normal Values | |Abnormalities | | |
|WBC | | | | |
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|HGB | | | | |
|HCT | | | | |
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|PLATELET | | | | |
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|Na | | | | |
|K | | | | |
|BUN | | | | |
|CREAT | | | | |
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|ANC | | | | |
|(chemo pts.) | | | | |
|Other | | | | |
Complete List of Nursing Diagnoses
(written in proper 3 part statements)
NURSING CARE PLAN Student:
|Two Nursing Diagnoses |Nursing Interventions |Rationale for each intervention |Evaluation |
|1 Measurable goal for each diagnosis |Minimum of 2 interventions for each |Document source and page number |Evaluate the goal, outcome, and objectives. |
|3 Measurable expectations for each goal |expected outcome (please number) |for each |Include measurable evidence. |
| | | |Was the goal met or not? |
|Nursing Diagnosis |The nurse will: | | |
| |1. A. | | |
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|Goal: | | | |
| |B. | | |
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|Expected Outcome | | | |
|1) |2. A. | | |
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| |B. | | |
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| |3. A. | | |
|3) | | | |
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| |B. | | |
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NURSING CARE PLAN Student:
|Two Nursing Diagnoses |Nursing Interventions |Rationale for each intervention |Evaluation |
|1 Measurable goal for each diagnosis |Minimum of 2 interventions for each |Document source and page number |Evaluate the goal, outcome, and objectives. |
|3 Measurable expectations for each goal |expected outcome (please number) |for each |Include measurable evidence. |
| | | |Was the goal met or not? |
|Nursing Diagnosis |The nurse will: | | |
| |1. A. | | |
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|Goal: | | | |
| |B. | | |
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|Expected Outcome | | | |
|1) |2. A. | | |
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| |B. | | |
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| |3. A. | | |
|3) | | | |
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| |B. | | |
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