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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