NURS 317L Pediatrics Nursing Process Worksheet.
NURS 317L Pediatrics Nursing Process Worksheet.
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Student Date Patient / Client Initials Facility Room Diagnosis RUHS Page 1 of _____ Allergies Vital Signs Temp:______ Pulse:_____ RR:_______ BP:_______ O2 Sat:________ Pediatric floor 34____ Medication – Trade name / Generic Time Due Dose ordered & Appropriate Dosing Parameters Calculation of Dosage Calculation of Dosage Calculation of Dosage Calculation of Dosage Class of Medication & Action of Medication (pharmacology) Why is THIS patient getting THIS medication Potential Side Effects of Medication Parameters for administering medication Student Name: _______________________________________Patient / Client: _________________________ Date: _______________ Page # ___________ Medication – Time Dose ordered & Class of Medication & Why is THIS patient Potential Side Parameters for Trade name / Due Appropriate Dose Action of Medication getting THIS Effects of administering Generic Parameters (pharmacology) medication Medication medication Calculation of Dosage Calculation of Dosage Calculation of Dosage Calculation of Dosage Calculation of Dosage Course: NURS 317L NURSING PROCESS WORKSHEET Date: ____________________________________________________________________________________ Student Name: Faculty Name: A. Visaya, RN Instructions: Each clinical day each student will develop a nursing process outline for one patient of their choice. These are quick writes and should be done throughout the shift and not taken home. These will be discussed in post conferences with the faculty. The outline will be as follows: Assessment (Based on systems: cardio, resp, GI/GU, mobility, Neuro, Safety, skin, pain, psychosocial) Obj:______________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Subj:_____________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Nursing Diagnosis (2) Must be prioritized. Must be Nanda using three part statement (Based on systems: cardio, resp, GI/GU, mobility, Neuro, Safety, skin, pain, psychosocial) Stem (DX): Etiology (Cause): as evidenced by (Signs and symptoms) Abnormal Assessment Findings. (1)_______________________________________________________________________________________ _________________________________________________________________________________________ (2)_______________________________________________________________________________________ _________________________________________________________________________________________ Planning (Patient goals) Must be SMART goals Pt. will (verbalize, demonstrate, be able to, increase & maintain, or decrease & maintain) by the: (end of shift, end of day, discharge day) or within: (two hours; 12 hours, etc.) _________________________________________________________________________________________ _________________________________________________________________________________________ Implementation (Specific nursing interventions that were performed during your shift): Must contain the following: Assess {observe, palpate, percuss}; Monitor; Administer; Collaborate w/ specific multi-disciplinary team; & Teach _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Page 1 of 2 Course: NURS 317L NURSING PROCESS WORKSHEET _________________________________________________________________________________________ _________________________________________________________________________________________ Evaluation (What was the outcome: Goal; Met or Not met or Partially met and How to revise.) _________________________________________________________________________________________ _________________________________________________________________________________________ Nursing Application Assessment Include activities throughout the day performed in relation to the following NCLEX content categories. See content category examples below as cited by NCSBN Management of Care _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Safety and Infection Control _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Basic Care and Comfort _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Management of Care: providing and directing nursing care that enhances the care delivery setting to protect clients and health care personnel. Related content includes but is not limited to: Advance Directives. Advocacy, Assignment, Delegation and Supervision, Case Management, Client Rights, Collaboration with Interdisciplinary Team, Concepts of Management, Confidentiality/Information Security, Continuity of Care, Establishing Priorities, Ethical Practice, Informed Consent, Information Technology, Legal Rights and Responsibilities, Performance Improvement (Quality Improvement), Referrals Safety and Infection Control: protecting clients and health care personnel from health and environmental hazards. Related content includes but is not limited to: Accident/Error /Injury Prevention, Emergency Response Plan, Ergonomic Principles, Handling Hazardous and Infectious Materials, Home Safety Reporting of Incident/Event/Irregular, Occurrence/Variance, Safe Use of Equipment, Security Plan, Standard Precautions/Transmission- Based Precautions/Surgical Asepsis, Use of Restraints/Safety Devices Basic Care and Comfort: providing comfort and assistance in the performance of activities of daily living. Related content includes but is not limited to: Assistive devices, Elimination, Mobility/Immobility, NonPharmacological Comfort Interventions, Nutrition and Oral Hydration, Personal Hygiene, Rest and Sleep Page 2 of 2 Pt is 18 months old, no allergies, weight 11.7 kg, height is 73cm admitted on 6/20/21 due to dog bite to right side of her face, last bowel movement is 6/45/21,hx of hemihypertrophy, has cellulitis to right face On contact and droplet isolation for rsv virus Medications; Tylenol 650mg/5ml solution oral ordered dose 15mg/kg, administering dose is 175mg q6hrs prn Ampicillin sulbactactan 879mg, NaCl 0.9 29.3ml intermittent,ordered dose ampicillin 200mg/kg/day, administering dose is 879mg at 58.6 ml/hr D5 and 0.9 NaCl with potassium chloride 20mEq/l infusion at 44ml/hr IV Continuous Mupirocin/Bactroban 2% ointment topical to right side of face