Care Plan

OXYGEN

ANALYSIS

NEUROLOGICAL ASSESSMENT

Pt/family hx of impairment:

Neuro symptoms:

1. Headache

2. Emesis/projectile vomiting

3. Irritability

4. Sunsetting eyes

5. Change in LOC

6. Decrease in GCS score

7. Decreased eye contact

8. Pupil dysfunction

9. Cranial nerve dysfunction

10. Seizures

Fontanels/Suture lines

CSF drainage: nose, ears

Head circumference

Tufts of hair at sacral area

Mental status

1. LOC/State of Consciousness

2. Pediatric Glasgow Coma Scale

Best Eye Opening

Best Motor

Best Verbal

Total Score

Pupils (Size, Equality, Reaction to light)

Motor:

Peds: Gross/Fine motor movement

Reflexes

Strength and Movement of Extremities

Analysis of normal related to growth and development:

OXYGEN

ANALYSIS

NEUROLOGICAL ASSESSMENT

Vital Signs

Medications:

Support devices/ Treatments

Labs

Diagnostic Tests

Teaching

OXYGEN

ANALYSIS

RESPIRATORY ASSESSMENT

Pt/family hx of impairment:

Assessment:

Respiratory rate

Breath sounds

Dyspnea

Orthopnea

Skin Color

Restlessness

Irritability

Fatigue

Level of Consciousness

Drowsiness

Anxiety

Headache

Vertigo

Thoracic exam

Shape & Symmetry

Labored/unlabored

Retractions

Nasal flaring

Stridor

Grunting

Posture

Capillary Refill

Activity tolerance

Chest expansion

Pursed lips

Cough/Nasal drainage

Frequency

Sputum/Nasal drainage

Color

Amount

Consistency

Splinting

Analysis of normal related to growth and development:

OXYGEN

ANALYSIS

RESPIRATORY ASSESSMENT

Medications

Diagnostic Tests

Labs

ABG’s pH___pCo2___HCO3___pO2___O2 Sat___

Support Devices

O2 L/min

Croup tent

Venti Mask

Ventilator/ CPAP

Treatments:

Incentive Spirometer

Chest PT

Humidifier

Teaching:

OXYGEN

ANALYSIS

CARDIOVASCULAR ASSESSMENT

Pt/family hx of impairment:

Cardiac: Present/Past Illness and History:

1. Chest pain

2. Orthopnea

3. Dyspnea

4. Fatigability

5. Growth delays

6. Squatting

7. Edema

8. Dizziness

9. Freq. Resp. Infections

10. Chromosomal abnormalities

11. Prematurity

Assessment:

Vital Signs

Cardiac Rate, Rhythm (also PMI)

Murmurs, Rubs, Thrills

Peripheral Pulses (strength/equality)

Skin color

Cyanosis

Periorbital/peripheral edema

Clubbing

Chest shape

Neck Vein Engorgement/abnormal pulsation

Homan’s sign

Analysis of normal related to growth and development:

OXYGEN

ANALYSIS

CARDIOVASCULAR ASSESSMENT

Medications:

Diagnostic Tests:

Labs:

Support devices:

Treatments:

Teaching:

NUTRITION

ANALYSIS

GASTROINTESTINAL ASSESSMENT

Pt/family hx of impairment (also hepatology):

GI symptoms:

1. Anorexia

2. Nausea/vomiting

3. Heartburn

4. Fatigue

5. Thirst

6. Difficulty swallowing

7. Dyspepsia

Assessment:

Skin Color

Abdomen (size, shape, auscultation, percussion and palpation)

Umbilical site (hernia)

Hydration

Teeth/Dental caries

Mucous membrane

Condition of mouth & throat

Height Weight

Growth Charts Ht/Wt %

Usual diet

Number and times of meals /day

Usual

Current

Food preferences

Fluid Intake

8 hr total

24 hr total

Usual Bowel habits (potty trained)

Last BM:

Description:

Analysis of normal related to growth and development:

NUTRITION

ANALYSIS

GASTROINTESTINAL ASSESSMENT

Labs:

Medications:

Diagnostic Tests:

Treatment Accessories:

IV fluid

TPN/PPN

Tube Feedings

Teaching:

NUTRITION

ANALYSIS

ENDOCRINE

Pt/family hx of impairment:

ENDOCRINE ASSESSMENT

Irritability

Poor feeding

FTT

Vomiting

Constipation

High fevers

Excessive thirst (polydipsia)

Excessive urine production (polyuria)

Enuresis (nocturnal bed wetting)

Changes in hair and nails

Medications

Diagnostic Tests

Labs

Supportive Devices and Treatments:

Teaching:

DIABETES ASSESSMENT

Pt/family History of Diabetes:

Signs/symptoms glucose imbalance

Accuchecks

Complications of Diabetes

Medications:

Diagnostic Tests:

Labs:

Supportive Devices and Treatments:

Teaching:

Analysis of normal related to growth and development:

ELIMINATION

ANALYSIS

GENITOURINARY/FLUID BALANCE ASSESSMENT

Pt/family hx of impairment (bladder/kidney):

Usual urinary pattern/potty training

Alterations from normal:

1. Flank tenderness

2. Pain or burning

3. Urgency

4. Frequency

5. Suprapubic tenderness

6. Incontinence

7. Retention

8. Bladder distention

9. Blood

10. Meatus placement

11. Assess for testes

12. Other

Assessment:

Abdomen (Auscultation, Percussion, Palpation)

Mucous membranes

Thirst

Poor perfusion

Wt. gain or loss

Growth retardation

Pruritus

Edema

Bruising

Fatigue

Change in LOC

Analysis of normal related to growth and development:

ELIMINATION

ANALYSIS

GENITOURINARY/FLUID BALANCE ASSESSMENT

Urine Color

Odor

Output 8 hr

24 hr

Genitalia

External genitalia exam

Tanner stage

Male Prostate problems

Urethral discharge

Female LMP

Vaginal discharge

Unusual bleeding

Medications:

Labs:

Diagnostic tests:

Support devices:

Treatments:

Teaching:

SAFETY

ANALYSIS

MUSCULOSKETAL ASSESSMENT

Pt/family hx of impairment or physical disability/injury:

Assessment:

Pain in affected extremity

Neurovascular status (Circulation, motion, sensation of injured extremity)

Symmetry of extremities/shoulders

Spine curvature/scoliosis

Equal movement

Symmetry of buttocks/leg folds

Hip clicks

Club foot

Webbing of digits

Limb discrepancy

Toddler

Genu Varum (bow leg)

Genu Algum (knock knee)

Presence of

Casts

Braces

Traction

Limitation in ADL’s

Fatigue/activity intolerance

Exercise habits

ROM (all joints)

Skeleton

Posture

Gait

Muscular strength

Analysis of normal related to growth and development:

SAFETY

ANALYSIS

MUSCULOSKETAL ASSESSMENT

Diagnostic tests:

Labs:

Medications:

Support Devices:

Treatments:

Physical Therapy consult:

Teaching:

EMOTIONAL SAFETY

Sense of security:

Fears:

SAFETY

ANALYSIS

INTEGUMENTARY ASSESSMENT

Pt/family hx of impairment:

Immunizations:

Factors influencing skin integrity:

Intake and output

NPO

Perspiration

Incontinence

Level of activity

Turns self

Nutritional status

Fluid needs

Calorie needs

Assessment:

Appropriate color

Pink nail beds, conjunctivae, soles of feet, palms of hands

Acrocyanosis

Temperature

Birthmarks

Lanugo

Nevi

Tissue integrity/location of change

Skin turgor Lesions

Edema Petechiae

Abrasions Pressure ulcers

Bruises Rashes

Lacerations Surgical incision

Surgical dressings and drains:

Diagnostic tests:

Labs:

Medications:

Support Devices/Treatments:

Teaching:

Analysis of normal related to growth and development:

SAFETY

ANALYSIS

INTEGUMENTARY ASSESSMENT

MECHANICAL ASSESSMENT

Risk factors

Vision impaired

Glasses

Auditory impaired

Hearing aids

Reflexes grossly intact

Mechanisms that depress the CNS

CHEMICAL ASSESSMENT

Allergies

Substance abuse

COMFORT

ANALYSIS

PAIN ASSESSMENT

Pt/family History of Pain

Pain/discomfort assessment:

1. Onset

2. Duration

3. Location

4. Intensity (0-10)

5. Pain Scale used

6. Radiation

7. Quality

8. Precipitating Factors

9. Alleviating Factors

Recent stressful life events

Non Verbal

Verbalizes feelings of pain

Physical Manifestations

Medications (pain):

Diagnostic Tests (pain):

Treatments (pain):

Teaching:

SLEEP

Hx of problems with sleep

Sleep environment

Hours slept/night

Position preferred

Naps during the day

Analysis of normal related to growth and development:

COMFORT

ANALYSIS

PAIN ASSESSMENT

SLEEP cont’

Sleep aids(pillows, toy, meds, food)

Signs/symptoms of sleep deprivation

Teaching:

FEVER

History of problems with fever/infections

Temperature on Admission

Progression

Current

Skin Color

Tissue Turgor

Thirst

Urinary Output

Medications

Diagnostic Tests:

Labs:

Support Devices/Treatments:

Blanketrol

Treatments (sponge bath)

Teaching:

Analysis of normal related to growth and development:

COMMUNICATION

ANALYSIS

History of communication problems:

Approach used:

Deficits:

Vision, Speech or Hearing

Corrective Devices

Eyeglasses

Contacts

Hearing Aids

Sign Language

Other

Chief method of communication

Language development

Interaction with caregiver

Interaction with staff

Appropriate Developmental Level:

Cognitive

Motor

Social

Obstacles to communication

Non-verbal behavior

Facial expressions

Use of touch

Gestures

English

Reads

Writes

Understands

Comprehension Ability

Alternate forms of communication:

Diagnostic tests:

Support devices:

Treatments:

Teaching:

PSYCHOSOCIAL

ANALYSIS

Developmental Level: (Is child at level, if not, what level and why?)

Erickson

Piaget

Use of Play

Motor Skills:

Gross

Fine

Social Skills

Cognitive Skills

Family Structure

Support System

Stressors (sleep, finance, other children, etc)

Effects of Hospitalization

Coping Mechanisms/Effectiveness/Appropriateness

PSYCHOSOCIAL

ANALYSIS

Friends-interactions, appropriateness

Hobbies, sports, activities

School-missing, makeup, friends, grades, etc

Risk Behaviors:

Drug, alcohol, smoking, peer pressures, sex, speeding, etc

Hospitalization

Response of child, & parent

Response to illness child & parent

Response to equipment

Fears

Adaptation to Chronic Illness child & parent

Caregiver Involvement

Who assists with cares during your shift

Appropriateness of interactions

Cultural/Spiritual Practices

Concerns of Abuse

Any Interactions that concern you

Teaching

TEACHING/LEARNING

ANALYSIS

History of problems which may affect teaching/learning

Current health problems

Teaching is directed at

Barriers to Learning

Developmental level of learner

Baseline Knowledge level of learner

Teaching given via:

Verbal

Written

Demonstration

Other

Content taught

Understanding accessed via

Include attached to your care plan Two teaching handouts provided (actual or potential) to your patient, and teaching that you provided with the material

DISCHARGE PLANNING

ANALYSIS

Follow up appointment:

Time, transportation, etc.

Meds:

Diet:

Activity:

School/Work:

Treatment:

Ability of care to be provided at home (meds, diet, tx, etc.)

Safety:

Outside referrals:

Social Services Referral: