Pediatric Care Plan for Strep Throat, Wheezing, and Asthma Exacerbation

Nursing Student:

 

Patient Initials/Age/Sex:

Handoff

Pretend you are handing off care for this client to another provider. Should include (but not limited to) health history, allergies, HPI (if applicable), short- and/or long-term health goals.

Pathophysiology

Briefly describe the patho of your patient’s active or potential disease process as if you were describing it to the patient at their developmental stage (3-4 sentences). If your patient is less than 5 years old, address their caregiver.

Do not cut and paste from resources.

Topic:

Description:

Reference(s):

Physical Assessment

VS Time

Temp (route)

HR (location)

RR

BP

SpO2 (O2 need or RA)

Assessment Findings:

Chart for each system. Do not chart by exception (“WNL”). Bullet points ok.

 

Each system on this column should be filled out.

Analysis:

?  Select only 3 priority systems to analyze. (You do not have to analyze every system).

?  Explain why this system is a priority for this patient.

?  If findings are abnormal, relate to the patient's actual/potential disease process(es).

?  If findings are normal, describe what you might see if there were complications or if the patient’s condition declined.

General/Pain assessment/Scale used:

 

Heent:

 

Resp:

 

Cardiac:

 

GI/GU/Repro:

 

MSK/Neuro:

 

Skin:

Lines, tubes, and drains as applicable:

 

Psychosocial:

Briefly describe interactions/observations of the patient and their psychosocial environment with attention to factors that may influence nursing decision-making (3-5 sentences).

 

Tests/Procedures/Labs:

Describe 2 priority procedures or labs that have/would influence your nursing decision-making for the disease process described above. (Eg: peak flow testing for asthma or urine culture for neonatal fever)

Atraumatic care: Include developmentally-appropriate coping skills/nurse coaching for during the procedure. (Actions you would take if were present during the procedure/event. How can we incorporate atraumatic care principles?)

Test/procedure/lab:

How can this information influence decision-making?

Atraumatic care ideas:

Test/procedure/lab:

How can this information influence decision-making?

Atraumatic care ideas:

Medications:

For students in outpatient settings: your instructor will give you further directions and an alternate template.

?        Copy the orders from the MAR. Prioritize 4 medications (you may consult with your instructor). Complete the row for these 4 meds.

?        Tailor side effects to your patient and clinical relevance. Actions should be beyond monitoring and assessment.

?        For dose calculations, please refer to Lexicomp for dosing, and paste the recommended dosing scheme that you used. Type out the calculations that you made to determine if the dose is safe. (Your instructor should be able to follow your math trail.)

?        If the dose is not appropriate, discuss possible actions and/or rationales.

Patient weight:

 

Order from MAR

Drug Category (class) and relevant MOA

Patient-specific reason(s) and rationale(s)

5 prioritized side/adverse effects +
2 priority nursing actions

Dose Calculations.

Is the dose appropriate?

(Add more if needed)

 

 

 

 

Development

How would you communicate with this patient based on milestones achieved or not achieved? Include observed examples to support your decisions.  (4-5 sentences).

Nursing Decision-Making

?  What are this patient’s 2 highest priority active or potential problems? (eg: What acute or chronic conditions may be a risk? What is keeping the patient from their baseline health status?) Ok to use non-NANDA language.

?  What can you do about these problems? Include nursing-driven interventions beyond following provider orders and monitoring. These actions are different from assessment and monitoring and may include teaching interventions.

?  Why did you select these actions? Support with relevant and recent EBP.

Problem 1:

Action(s):

Rationale(s):

Reference(s):

Problem 2:

Action(s):

Rationale(s):

Reference(s):