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Azusa Pacific University
School of Nursing
Nursing Process Data Form
UNRS 314
A. Identifying Data
Student: ________________________________________________________________
Childs Initials: ________Age: ____ Gender: _______Allergies: ___________________
Primary Language: ______________Ethnicity: ____________ Religion:____________
Parents Marital Status: _________ Parents Occupation: ___________________________
Insurance: _______________________________________________________________
Family Composition: ______________________________________________________
Home/Living Situation: ____________________________________________________
Medical Diagnosis:________________________________________________________
B. Biological Subsystem
1.
Past Medical/Surgical History/Chronic Conditions (birth history, if applicable
and for all infant under 1 year):
2.
Recent Medical History/Course of Hospitalization: (This should be a time-line of
events leading up to the hospitalization and hospital course proceeding day of care.)
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3. Medical Diagnoses: List chronic, acute and rule out admitting diagnoses)
4. Home Medications: List over- the- counter meds, herbs, and vitamins used and why
used and when the last time they were administered.
5. Physical Assessment: (Download a form from CDC.gov and graph out
height/weight or BMI for the school-age or older)
If the parents do no know exactly what immunizations the child has had please look
up what they should have had at their age.
Ht _____ Wt______ BSA________ BMI __________ HC ________________
Immunization Status
________ Dtap
________ Hep B
________Polio
________MMR
________ Hib
________ PCV
________ Varicella ________ Heb A
VITAL SIGNS:
Time
Temp
PAIN ASSESSMENT:
Time Pain Tool Pain
Used
Rating
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Pulse
(apical/radial)
Resp
BP
Pulse Ox
Pain Description
(OLDCART)
Functional
Pain Goal
Pain
Response To
Medication
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(Remember to keep age appropriate review pediatric physical assessment in Bowden text or you
physical assessment text)
General Appearance:
Skin: Color ____________ Turgor ___________ Temp ________________ Lesion ________________
Rashes _______________________________ Birth marks / pigmentations _______________________
Incisions / wounds ____________________________________________________________________
MUSCULOSKELETAL:
Activity Level __________ROM __________Gait/Mobility _________ Posture _____________________
Hip Assessment / infant ____________________ Feet _________________________
Back (scoliosis) _______________________________________________________________________
Cast/ traction__________________________________________________________________________
Neurovascular assessment ______________________________________________________________
NEUROLOGICAL: (Describe how assessed / must be age appropriate)
Fontanels _________ Shape _____________ Abnormalities noted ______________________________
Level of consciousness, alert, orientation, memory ____________________________________________
______________________________________________________________________________________
Pediatric Eye Response ________
Pediatric Motor Response ______
Pediatric Verbal Response _____
Pediatric Total Coma Scale _____
Age appropriate evaluation: How did you evaluate? Are normal limits for age?
Speech ________________________________________________________________________________
Sensory _______________________________________________________________________________
Motor ________________________________________________________________________________
______________________________________________________________________________________
Vision ________________________________________________________________________________
______________________________________________________________________________________
Hearing _______________________________________________________________________________
______________________________________________________________________________________
Reflexes (New born reflexes must be tested in all infants under 6 months)
______________________________________________________________________________
______________________________________________________________________________________
CARDIOVASCULAR:
Heart Sounds: Rate __________
Rhythm ___________ PMI _____________ Murmurs: ___ Y ___ N
Pulses: R/L Radial _____________ Brachial ______________ Femoral __________ Pedals _________
Capillary Refill _____________ Skin color/temp ____________________ Edema ___________________
Cardiac Monitor with Alarm Set ____________Y/N______ Parameters ___________________________
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PULMONARY:
Respirations: Rate ______ Rhythm______ Depth_____ Effort/Ease_________
Describe: Breath Sounds (bilateral comparison) R/L – Crackles (fine, coarse) Wheezes (inspiration,
expiration), Diminished, Absent. Chest movement: retractions, nasal flaring, head bobbing, grunting.
_____________________________________________________________________________________
_____________________________________________________________________________________
Oxygen Needs: (mask, cannula etc.) Oxygen ____________ or Room Air _________________________
Pulse Oximetry range :_____________ Alarm Parameters ______________________________________
GASTROINTESTINAL:
Diet__________________ Appetite ________________ Intake% ___________N/V __________________
Kcal per day needed _________________________ Actual Calorie intake _________________________
Intake: PO _____ (If an infant give how often feeding) Breast feeding / how often ___________________
Enteral nutrition: NG Tube _________________ G Tube or J tube ________________
Mouth / palate ___________________________Number of teeth/braces / caries____________________
Abdomen: (soft, distended, ascites, stomas): _________________________________________________
Bowel sounds: Location_______ Activity_________
Bowel Patterns _____________ Last BM __________ Stool Characteristics ________________________
GENTOURINARY:
Urine: Output (hourly, 8º, 12º, 24º) ___________ Characteristics __________________________
Catheter ________________________
Genitalia: (Tanner Scale) Female____________________ Male____________________________
6.
List of abnormal physical findings and include anything from the parent /
child history that is of a concern
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7.
Clinical Manifestation of Current Condition:
Expected Manifestations
according to Literature for
each medical diagnosis
Assessment on Day of
Admission or Health Care
Visit According to Chart
Assessment on Day of Care
Focused only – do not forget
to include vital signs
8.
Laboratory Tests: (WNL is acceptable, only list abnormal value; every
laboratory test must have a rationale even if the results are normal) How does abnormal
value relate to diagnosis?
Test:
Results:
(Date/Time)
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Rationale For Test Being
Performed On This Child:
Rationale for Abnormal
Test Results: (source)
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9. Diagnostic Tests / Diagnostic Procedures / Surgical Procedures
Test:
Results:
(Date/Time)
Rationale For Test Being
Performed On This Child:
Rationale for Abnormal
Test Results: (source)
10. Treatments: Physician orders, medications, respiratory treatments, physical therapy,
occupational therapy, social service referral and standard nursing interventions.
(Suctioning, ambulate, TCDB, pulse oximetry, oxygen administration, dressing change,
NG tube, tube feeding, IV fluids and medications) Medications must included drug
classification and action under rationale for treatment and nursing intervention include
how to administer and major side effect.
Treatment
Rationale for Treatment
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Nursing Interventions
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C. Psycho-social Subsystem
1. Family Evaluation: Theorist of choice - Bowden Chapter text
Strengths
Challenges
2. Cultural Influences/Health Beliefs and Values: Please use cultural
assessment tool for this section:
Strengths
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Challenges
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3. Spiritual Assessment: Use spiritual assessment tool
Strengths
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Challenges
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E. Nursing Diagnosis/Collaborative Problems
1.
Patient Care Needs for the Day:
2.
Prioritized Nursing Diagnoses/Collaborative Problems: (one must be family
ability to cope based on the cultural and spiritual assessment)
Nursing
Diagnoses/
Collaborative
Problems
Related To:
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Manifested By:
Mutually
Identified
Problem
(Y/N)
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Plan of Care: One physical and one developmental, cultural, spiritual or family nursing
diagnosis.
1. Key assessment facts for Nursing Diagnosis 1 / Collaborative problem
Nursing Diagnosis: # 1 Physical (Must include a clinical or research article to support
nursing interventions) Text book references should account for 25% maximum.
Patient goals or outcomes: must be specific and measurable
Nursing / Health Care Interventions
Rationale
Evaluation of each Intervention
Modifications Potential or Actual
Evaluation of Goals / Outcomes
Modifications Potential or Actual
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References for this section: You must use at least one journal or research article – Carpanito is
not an acceptable reference for this area. Use of the Bowden text and books from previous
courses can not be use exclusively. The Bowden pediatric procedure manual can be used as a
reference.
Key assessment facts for Nursing Diagnosis 2 / Collaborative problem
Nursing Diagnosis #2 (developmental, cultural, spiritual or family nursing diagnosis. Knowledge deficit
can be used if you have a very specific goal in mind – knowledge deficit regarding disease process is not
acceptable unless it is a new long-term diagnosis such as diabetes, ulcerative colitis, asthma – check with
clinical instructor is you have questions)
Patient goals or outcomes: must be specific and measurable
Nursing / Health Care Interventions
Rationale
Evaluation of each Intervention
Modifications Potential or Actual
Evaluation of Goals / Outcomes
Modifications Potential or Actual
References used for this section:
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3.
Discharge Needs: Community Referral, Follow-up Appointments, Medications,
Equipment and Long Term Care Concerns.
List Educational Needs
for caretaker /child
Teaching methods used: (be specific about the discharge
plan even if some else will discharge patient)
Evaluation and modification of teaching:
Medications /
treatments/ equipment
needed at time of
discharge
Do they know how to administer the medication and
where to fill the prescription?
Do they know how to administer any treatments?
Do they have the equipment needed?
Referrals / follow-up
care
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Reference for this section: If you use internet resources from the hospital web-site
please include.
H. References
You must use articles from a journal or Internet from a reliable professional source. These can be a clinical or
research article. You must include a copy of the article used to obtain credit. You must document use of the
article in your paper to receive credit. Remember any information you take from a text book must be documented.
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Must include:
Spiritual assessment tool
Cultural assessment tool
Growth chart from CDC.gov with plotted height, weight, HC, or BMI for the school-age or
older.
Article: highlighted would be preferred.
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