COMPREHENSIVE NURSING CARE PLAN



Pediatric Comprehensive Nursing Care Plan

Grading Criteria

(See attached page for guideline descriptions)

|Content |Points |Points Achieved |

| |Possible | |

| Format |3 | |

|Client Profile |2 | |

|Client Health History |3 | |

|Student Nursing Assessment |4 | |

|Pathophysiology |4 | |

|Diagnostic Tests |4 | |

|Medications |4 | |

|Developmental Assessment |2 | |

|Plan of Care | | |

|Diagnosis |3 | |

|Expected Outcomes |3 | |

|Implementations/Interventions |3 | |

|Rationale |2 | |

|Evaluation r/t Expected Outcomes |3 | |

|Total Possible |40 | |

Comprehensive Nursing Care Plan

CLIENT PROFILE

Client Initials:

Age:

Gestinational Birth (if applicable):

Gender:

Allergies:

Date of Admission:

Code Status:

Height: Weight on Admission (lbs): (kg):

BSA:

Admission VS

|Temp |BP |HR |

|RR |Pain |O2 |

Admitting Dx:

Pertinent Hx:

Current Status

VS this shift:

|Temp |BP |HR |

|RR |Pain |O2 |

|Temp |BP | |

| | |HR |

|RR |Pain |O2 |

Activity Level:

Diet:

Current Weight:

Location of IV Site(s): IV Solution(s) and Rates:

PCA/Epidural (drug, concentration, dosage):

Support Tube(s) and Location(s):

Intake this Shift (differentiate route(s)): Intake last 24 hours (differentiate route(s)):

Output this Shift (differentiate route(s)): Output last 24 hours (differentiate route(s)):

Shift Urine Output (mg/kg/hr):

Client Health History

Student Nursing Assessment

Subjective Data

Neurological

Cardiovascular

Respiratory

GI

GU

Musculoskeletal (include Functional Status)

Integument (include condition of any invasive site(s), incisions)

Pathophysiology

Pertinent Labs & Diagnostic Testing

|Lab/Diagnostic Findings |Client Specific Rationale for |Expected Assessment Findings |Follow-up measures needed and/or |

|include date of test |Pertinent Test Results | |additional diagnostic tests expected|

|(normal values) | | | |

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Medications

|Medications (Trade &|Client Specific Rationale/ |Dose |Pertinent |Common Side |Pertinent Nursing Implications/|

|Generic) |Mechanism of Action |Route |Associated |Effects/ Observed |Additional Medications Expected|

| | |Time |Diagnostic Tests|Side Effects | |

| | |Frequency | | | |

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Developmental Assessment

Developmental Stage (Erickson’s)

Growth and Developmental Milestones

|Norms for Age |Actual |

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Respone to Hopsitalization:

|Norms for Age |Actual |

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Impact of Illness on ADL’s and Development:

Plan Of Care

|Nursing Dx #1 |Expected Outcome |

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|Implementation |Rationale |

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|Evaluation r/t Expected Outcome |Suggested Modifications |

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|Nursing Dx #2 |Expected Outcome |

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|Implementation |Rationale |

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|Evaluation r/t Expected Outcome |Suggested Modifications |

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|Nursing Dx #3 |Expected Outcome |

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|Implementation |Rationale |

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|Evaluation r/t Expected Outcome |Suggested Modifications |

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Work Cited

(APA Format)

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