Professional Documents
Culture Documents
Medication/Doctor’s Normal Why is this child receiving this Assessment for therapeutic effects and side effects Gave?
Order Dose Range Medication?
Drug Name: Child:
Order:
safe dose
Classification: range: Is this a safe dose?
Drug Name:
Order: Child:
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Student: Date of Admission: Today's Date
Patient's Initial: Age: Sex:
Diagnosis: Erikson's
Developmental Task:
Normals Yes No Comments
Physical:
Height:
Weight:
Dentition:
Temperature:
Pulse:
Respiratory:
B/P:
Fluid Requirement:
Gross Motor:
Fine Motor:
Locomotion:
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Normals Yes No Comments
Cognition:
Socialization:
Vocalization:
Play:
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Basic Needs Objective Data Subjective Data Nursing Dx - Prioritize
A. Physiologic Respiratory rate at rest: Include subjective and
1. Oxygenation On exertion: objective indicators
Respiration Lung sounds:
Cough: nonproductive
productive (describe):
Pulse Ox.:
Retractions/Nasal Flaring:
Chest X-ray:
Bedtime rituals:
Activity level:
4. Nutrition Height:
Weight:
Percentile on growth chart:
Ht. Wt.
Preferred foods:
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Basic Needs Objective Data Subjective Data Nursing Dx - Prioritize
Appetite: Usual:
Current:
Type of diet at home:
At hospital:
Nausea/Vomiting
Bottle: Breast:
Cup: Sippy Cup:
Finger Foods:
Level of consciousness:
Pupils:
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Basic Needs Objective Data Subjective Data Nursing Dx - Prioritize
Head Circumference:
Percentile on growth chart:
7. Elimination Toiled Trained:
Bowel Last BM, Describe:
Bowel sounds:
Abd distention:
Passing flatus
Bladder Toilet trained:
Urine: Color, sensation and odor:
Amount: (24 hours)
Specific gravity:
8. Comfort Pain: Location:
Verbal and non-verbal behavior:
9. Sexuality Secondary sex characteristics:
Genitals: Discharge
Lesions
Testicles descended:
B. Safety and Security Lesions, incisions: (Use REEDA)
1. Physical Appearance of rash:
Mouth: Dentition:
2. Chemical/ Immunizations to date:
Microbial WBC:
Recent exposure to infectious diseases:
Allergies:
3. Thermal Temperature today:
Onset and history:
Cause:
Revised 12/08/10
Basic Needs Objective Data Subjective Data Nursing Dx - Prioritize
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COLLEGE LABORATORY
2. Apply the format for a written care plan for Nursing Care of
Mothers and Children to a prenatal mother.
PREREQUISITE ACTIVITY:
LABORATORY ACTIVITY
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Nursing Care Plan1
Date:___________Need:___________________________________________________
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Nursing Care Plan
Need:__________________________________________________________
Goal:__________________________________________________________
Evaluation of overall
goal:______________________________________________________
IMPLEMENTATION:_____________________________________________________
________________
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