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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.) L:Forms/ Nursing Data Form and Process kb 6/28/17 1 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 L:Forms/ Nursing Data Form and Process kb 6/28/17 Pulse (apical/radial) Resp BP Pulse Ox Pain Description (OLDCART) Functional Pain Goal Pain Response To Medication 2 (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 ___________________________ L:Forms/ Nursing Data Form and Process kb 6/28/17 3 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 L:Forms/ Nursing Data Form and Process kb 6/28/17 4 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) L:Forms/ Nursing Data Form and Process kb 6/28/17 Rationale For Test Being Performed On This Child: Rationale for Abnormal Test Results: (source) 5 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 L:Forms/ Nursing Data Form and Process kb 6/28/17 Nursing Interventions 6 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 L:Forms/ Nursing Data Form and Process kb 6/28/17 Challenges 7 3. Spiritual Assessment: Use spiritual assessment tool Strengths L:Forms/ Nursing Data Form and Process kb 6/28/17 Challenges 8 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: L:Forms/ Nursing Data Form and Process kb 6/28/17 Manifested By: Mutually Identified Problem (Y/N) 9 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 L:Forms/ Nursing Data Form and Process kb 6/28/17 10 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: L:Forms/ Nursing Data Form and Process kb 6/28/17 11 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 L:Forms/ Nursing Data Form and Process kb 6/28/17 12 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. 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. L:Forms/ Nursing Data Form and Process kb 6/28/17 13