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. | | |

|2) | | | |

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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. | | |

|2) | | | |

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| |3. A. | | |

|3) | | | |

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| |B. | | |

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