Ivy Tech Community College

NSG 113
Pediatrics Care Plan
Patient Initial __

Student Name _____________________

Admission Date __

Date(s) of Care___ Birth Date__________ Patient Age ___

Patient Diagnosis ___Date of Surgery, if applicable____ Allergies___________________

Diagnoses_____________________________________________________________________________
Development Appropriate for Age? Yes_____ No_____
Explain_______________________________________________________________________________
Ericksons Stage _______________________________________________________________________
Piagets Stage __________________________________________________________________________
Play Stage and Appropriate Play Items_____________________________________________________
______________________________________________________________________________________
Gordons Functional Health Patterns
Assessment Data (Include normal and abnormal)
I.

Health History/Health Perception

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:
II.

NUTRITION

METABOLIC

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

Diagnostic studies: List diagnostic studies that are ordered on this patient that relate to nutrition and metabolic, lymphatic
system, integumentary system, infection, shock and cancer.
__
III.

ELIMINATION

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

Diagnostic studies: List diagnostic studies that are ordered on this patient that relate to renal, genitourinary system,
gastrointestinal system, liver, gallbladder, pancreas, endocrine, infection, cancer, and elimination.

IV.

ACTIVITY - EXERCISE

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

Diagnostic studies: List diagnostic studies that are ordered on this patient that relate to cardiovascular, respiratory,
musculoskeletal, activity tolerance and endurance, fluid and electrolytes, shock, infection, and cancer.

___

V.

SLEEP - REST

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:
Diagnostic studies:

VI.

COGNITIVE - PERCEPTUAL

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

Diagnostic studies: List diagnostic studies that are ordered on this patient that relate to neurological, sensory, infection, cancer,
and mental health.
__

VII.

SELF PERCEPTION - SELF CONCEPT

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

VIII.

ROLE RELATIONSHIP

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

IX.

SEXUALITY - REPRODUCTIVE

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:
Diagnostic studies:
__
X.

COPING - STRESS TOLERANCE

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

XI.

VALUES - BELIEFS

SUBJECTIVE

OBJECTIVE

Nursing Diagnosis:

DISCHARGE NEEDS
List treatments: __

Special care or needs: ___

Special teaching: __
Follow up care or appointments: ___
Life expectancy: ___
Rehabilitation specify type: __
Return to: home

another facility

Home Health Care

Long Term Care

Assisted Living

Final Residence

PATHOPHYSIOLOGY
Disease Process:

Signs & Symptoms:

Diagnostic Studies:

Medical & Surgical Treatment:

Nursing Care:

CLINICAL COURSE
Why was the patient admitted and what changes have occurred since this admission?

What has been the response to treatment?

DIAGNOSTIC STUDIES
Lab studies and x-rays ordered:

Patient results (choose at least two of the above)

Name of test:
Normal values:
Patient values:
Significance (purpose of test, nursing preparation, explain abnormal values as they relate to the patient):

Name of test:
Normal values:
Patient values:
Significance (purpose of test, nursing preparation, explain abnormal values as they relate to the patient):

Attach a medication information sheet including generic and trade name, classification, dosage range, route, indication and actions, contraindications,
side effects, drug interactions, and nursing considerations and contraindications.
Medication Information Form
Classification
Indication and
Action

Medication
Generic &
Brand Name

Dose Range

Client Dose

Nursing
Considerations and
Contraindications

10

Side Effects/Drug
interactions

NURSING CARE AND TREATMENTS

Examples of treatments: Dressings, irrigations, incentive spirometer, breathing

treatments, traction, casts, splints

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Prioritization of nursing concerns

List all nursing concerns in order of priority.
Note: It is expected that if a problem is listed as numbers 1, 2, or 3 that these problems would be
addressed in the Care Plan. At least one problem should be related to the pathophysiology,
example: if the care plan is a heart patient, at least one nursing diagnosis should be related to the
heart disorder.

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(USE SEPARATE SHEET FOR EACH NURSING DIAGNOSIS)

Nursing Diagnosis: Remember to use a three part nursing diagnosisProblem, Etiology,
Symptoms

Goal: Use SMART criteria.

Actions with rationale: (Minimum of three)

Evaluation:
(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Is it
appropriate to keep with the original plan?)

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(USE SEPARATE SHEET FOR EACH NURSING DIAGNOSIS)

Nursing Diagnosis: Remember to use a three part nursing diagnosisProblem, Etiology,
Symptoms

Goal: Use SMART criteria.

Actions with rationale: (Minimum of three)

Evaluation:
(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Is it
appropriate to keep with the original plan?)

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(USE SEPARATE SHEET FOR EACH NURSING DIAGNOSIS)

Nursing Diagnosis: Remember to use a three part nursing diagnosisProblem, Etiology,
Symptoms

Goal: Use SMART criteria.

Actions with rationale: (Minimum of three)

Evaluation:
(Was goal achieved or not? If not, are there any actions which could help achieve that goal? Is it
appropriate to keep with the original plan?)

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