ࡱ> c Z4jbjbSS 11Z0]d.2,A5!|n n n n n n *嫸FLORIDA GULF COAST UNIVERSITY College of Health Professions School of Nursing 17 Questions to Answer Prior to Giving Care to Any Child Why is your child in the hospital? (in chart) *What kind of diet is your child on? 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) *Are you to keep track of your childs I&O? *What are you to test your childs urine for? Stool? *Does your child need to be weighed today? If yes, when? *What is the activity level ordered for your child? What time will you take his/her temperature? (graphic sheet) How will you take his/her temperature? (graphic sheet) *What other assessments are ordered to be done? neuro? neurovascular? 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) What rate is ordered for the IV? (IV sheet or plan of care) 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? *What other procedures are ordered for your child today? dressings? suctioning? chest PT? irrigations? ambulations? turning? ISB? At what time are you to do the procedures? What do we want to happen to this child before we can discharge him/her? 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 7:007:308:008:309:009:3010:0010:3011:00check ordershear reportsee instructortake vs assess eat or feedbathe IV I&O meds change dressingIV ISB irrigate CPT report off teeth/oral hairshave  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. Patients 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 childs manifestations): Usual treatment (cite your childs 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: ERIKSONS DEVELOPMENTAL STAGE:_______________________ VS _______________________ Psychosocial Development Pertinent developmental tasks/needsDescribe ObservationsOrganize in Denver II categories for children under six years of age, and in the following categories for Children over six years: 1. Cognitive 2. Social abilities/tasks 3. Physical growth and motor ability 4. Family relationships  Where do you place the child developmentally? (At what age for each category?)Write a brief summary on Eriksons stages for all patients. State conclusion as to whether child is on target for age by comparing with norms on left and Eriksons Developmental Stage.  FLORIDA GULF COAST UNIVERSITY College of Health Professions School of Nursing Student: ___________________ Date:___________ Medications Patients Weight ______kg Generic/trade names Dose, route, frequency Ordered for child. Give dose in mg, not cc. Please number drugs.Safe range 1. Calculate safe range for 24 hrs. State mg/kg guidelines. 2. Calculate patients dose for 24 hours.1. Drug Classification How drug works Desired effect for patient.Adverse EffectsNursing responsibilities when administering drug      FLORIDA GULF COAST UNIVERSITY College of Health Professions School of Nursing NURSING ASSESSMENT GUIDE* Childs Initials: Informant: Date: Birth date: Presenting Problem and Brief History of Present Illness: 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 childs age. 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 Childs 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 childs hospitalizations V. Developmental Patterns (discuss those appropriate to Childs 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 Mothers reaction to patients 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 Tanners Stage Abdomen bowel sounds masses femoral pulses tenderness distended; soft Genitalia testes descended circumcised urinary stream vaginal discharge adolescents Tanners 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__________ todays 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 Normal ValuesClients ValuesReasons for Clients AbnormalitiesNursing AssessmentNursing InterventionsWBC HGB HCT PLATELET Na K BUN CREAT ANC (chemo pts.) Other  Complete List of Nursing Diagnoses (written in proper 3 part statements) NURSING CARE PLAN Student: Two Nursing DiagnosesNursing InterventionsRationale for each interventionEvaluation1 Measurable goal for each diagnosis 3 Measurable expectations for each goal Minimum of 2 interventions for each expected outcome (please number)Document source and page number for eachEvaluate the goal, outcome, and objectives. Include measurable evidence. Was the goal met or not?Nursing Diagnosis Goal: Expected Outcome 1) 2) 3) The nurse will: 1. A. B. 2. A. B. 3. A. B.  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