Altoosi College University

Nursing department

Nursing care plan/ Third stage

Student's name:

Clinical instructor’s name:

Clinical area:

Date:

Score:

Comments:

Child health nursing care plan

1. identifying data base:

● Child initials :--------------------------------------------------
● Age:------------------------ sex-------------------------------
● Date of admission:--------------------------------
● Floor:------------------------- Room Number--------------------
● Source of data:------------------------------
● Medical diagnosis -------------------------------

‫هذني ما نريدهن‬
I1 Data base assessment:

- Health perception

-management patient.

1. Present history

a. Chief complaints upon admission

b. History of present illness ( describe)
2. past history
a. past medical and surgical history
b. Prenatal history.
● Length of gestation:-------------------------------------------
● Type of delivery------------------------------------------------
● Apgar score:----------------------------------------------------
● Birth head circumference:-------------------------------------
● child chest circumference-------------------------------------
● Any complication with the infant. During the first month of life.
-----------------------------------------------------------------------------

-----------------------------------------------------------------------------
 c. Immunization status:
● Vaccines received
● If yes (specify):------------------------------------------- ---------
--------
● If no (why):---------------------------------------------------------
---------
d. Family history:

3. Nutritional – metabolic pattern.

1. Child appetite (describe)-----------------------------------------------------------------------
------------------------------------------------------------------------------
2. Type of feeding :
a. Breast feeding ( number of feeding in 24 hours and duration)
b. Bottle feeding:
(Type of formula, amount, and number of feeding in 24 hrs.)

c. Regular diet:
● Number of meals and snacks in 24 hours.

● Amount of milk that the child drinks in the 24 hours.

● ( Does the child use a bottle or cups?)

4. Intravenous fluid.
● Type and amount.------------------------------------------------------------------
● Calculation of drops and calories.-----------------------------------------------

5. Fluid maintenance ( intake) ( calculate).

6. Any food restrictions or allergies:

7.Any gastric disturbances (specify and describe) Vomiting ,Diarrhea

4. Elimination pattern
Is he toilet trained.---------------------------------------------------------------------Habit,
color, consistency.----------------------------------------------------- ----------------------------
-------------------------------------------------------------------------------

● Any problems ( specify and describe):----------------------------------------------------

--------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------
---------------------------------------------------------
2. Bladder:

● Colour, amount, frequency in 24 hours.

● Any problems (enuresis, burning, oliguria, polyuria, ect....)
● Any assistance, device used:
 ● 5. Activity – exercise pattern:
1.Gross motor abilities (according to age).

2.Fine motor abilities (according age):

3.Self – care abilities or activities.

Use code:

1 = independent, 2= needs assistance, 3 = dependent)

Activity Code

Feeding

Bathing

Dressing

Toileting

Mobility

6. Sleep – rest patterns:-

1.. Sleeping hours in 24 hours:

* At night. ----------------------------------------

* Naps.--------------------------------------------

2. The child’s usual sleep routine: (Stories, security object ...etc)

3.Any problems related to sleep.( Insomnia, walking up, talking during

night,……etc.)

7. Cognitive – perceptual pattern:

1. Any sensory perception deficits (hearing, smell, sight, touch).

----------------------------------------------------------------------------------------------------

-------------------------------------------------------------------------------------------------- -
 2. Grade in school. ------------------------------------------

3. Problems related to school achievement:---------------------------------------------

-------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------
--------------------------

8. Role relationship pattern.

1. Does the child use language appropriate for age? ( Describe).

2. Relationship:

* With family members.

* With peers.

9. Coping – stress managements during hospitalization:

10.. Value belief pattern:

● Religion:-------------------------------------------------------------------------------
III. Physical Assessment ( objective):

1. Clinical data.
- Height or length ----------------------- Normal. -------------------------
- Weight ---------------------------------- Normal -------------------------
- Head Circumference (if appropriate) --------------- Normal. -----
2. Vital signs.
- Respiration rate. -------------------------------- Rhythm. ---------------------

- Temperature, (orally, Rectally, Auxiliary)--------------------------------------

- Blood pressure) if appropriate); -----------------------------------------------

3. Metabolic – Integumentary :

a. Skin (colour, temp, turgor, bruises, edema, rash, lesion etc.....)

b. Mouth.

- Gum (describe) -----------------------------------------------------------------

- Teeth (describe) ---------------------------------------------------------------------

- Soft palate (describe). --------------------------------------------------------------

c. Abdomen.

- Bowel sounds (Number 1minute) ------------- Absent. -----------------------

- Any abnormalities (Masses, distention ...... etc).

4. Neuro – Sensory:

a. Mental status.

- Orientation ----------------------------------------------------------------------

- Level of consciousness. -------------------------------------------------------

b. Speech, normal. --------------------------------------------------------------------------

- Difficulty (specify): -----------------------------------------------------------

c. Eyes.
- Condition -------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------

-Pupil's reaction to light----------------------------------------------------------------------

5. Muscular – Skeletal.

Range of motion of extremities.-------------------------------------------------------

IV. Investigations:

Type of test Normal value Result Date Indication

V. Medical Treatment

No Name of drug Rout of administration Time dose action Side effect

VI. Nursing Care Plan

Nursing Diagnosis Goals Nursing care plan Implementations Outcome
(evaluation)
VII. References

9.2. b .2. Daily Notes:

Child's name Hospital name:

Age: Sex: Date of Admission: / /

Weight: Ward No.

Height: Date of training: / /

Medial Diagnosis: Student’s Name:

Time & T. P. R. B/P. Urine Stool Type Medication DosageRout Side Investigations Results
date of effect
feeding
 Nursing Assessment: ‫اهم شي هو هذا الجدول‬// ‫عاجل‬
Nursing Planning Implementation Rational Evaluatio
diagnosis
Clinical Instructor’s Name: signature: Date:
Score: ( )