Pediatric Nursing Care Plan

Student Date
Instructor Course
Patient Initial Unit/ Room# DOB
Code Status Height/Weight
Allergies

Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10

 

History of Present Illness including Admission Diagnosis &
Chief Complaint (normal & abnormal) supported with Evidence Based Citations Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations

 

 

Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),
include dates and rationales supported with Evidence Based Citations
Past Medical & Surgical History,
Pathophysiology of medical diagnoses
(include dates, if not found state so)
Supported with Evidence Based Citations

 

 

Erikson’s Developmental Stage with Rationale
And supported by Evidence Based Citations Socioeconomic/Cultural/Spiritual Orientation
& Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations

 

 

Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each
(“At Risk for…” nursing dx) Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale
supported with Evidence Based Citations

 

 

 

 

 

Priority Nursing Diagnosis
(at least 2)
Written in three part statement
Planning
(outcome/goal)
Measureable goal during your shift
(at least 1 per Nursing diagnosis)
Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching
(at least 4 per goal) Rationale Each must be
supported with Evidence Based Citations Evaluation
Goal Met, Partially Met,
or Not Met
& Explanation

 

MEDICATION LIST

Medications (with APA citations Class/Purpose Route Frequency Dose (& range)
If out of range, why? Mechanism of action
Onset of action Common side effects Nursing considerations
specific to this patient