PN Program
CLINICAL PHYSICAL ASSESSMENT AND CARE PLAN
CHILDREN
STUDENT NAME: Tearia Hosendove
CLINICAL SITE/UNIT: CH3
CLINICAL DATE: 06/30/2023
Weight: 18.1 KG
DEMOGRAPHIC DATA: N/A
PATIENT INTIALS: HP
AGE: 6
Sex: F
Room: 315
Erickson's Psychosocial Stage of Development: Initiative VS. Guilt: Purpose (Age 3-6)
Piaget’s Cognitive Stage of Development: Preoperational Stage: Pretend Play (Age 2-7)
Allergies: Augmentin
Medical Diagnosis: Cleft Palate
PMH: Cleft palate
Adm date: 06/30/2023
Current Medical History: Cleft Palate, Repair of Nasolabial Fistula.
Surgical History: Repair of Nasolabial Fistula
CURRENT ORDERS:
Code Status: Full code
Diet: Pediatric Clear Liquid
VS frequency: Q4H
Room Air
Precautions: Fall Precautions
IVFS and Rate: N/A
Medications: Acetaminophen (Tylenol) 325mg/10.15ml suspension, 12.5mg/kg PO Q6H
Pulse Oximetry: 98%
Other: Incentive Spirometer Q2H while awake, Oxygen as needed
PHYSICAL EXAM (HEAD TO TOE)
Blood pressure: 87/52
Temperature: 97.3°F Auxiliary
Pulse: 73
Respirations: 24
O2 saturation: 98% Room Air
Pain score: 7 (rFLACC).
NEUROLOGICAL: Patient Alert and appropriate for age, Pupils equal, round, reactive to light, brisk dilation response. Verbal
communication appropriate for age.
HEENT: Symmetrical head. Round and symmetrical clear eyes medial to ears, no drainage present. Symmetrical ears lateral to
eyes, ear canal clear without discharge. Nose symmetrical, nasal mucosa pink and moist. Oral Mucosa is pink and moist.
Oronasal fistula repair assessed, red palate noted, sutures intact no drainage noted. Swallowing without difficulty noted.
RESPIRATORY: Clear & symmetrical lung sounds noted 2141: 98% Room Air. Unlabored breathing. No nasal flaring. No
refractions and no cough present.
CARDIAC: Regular cardiac rhythm, S1 & S2 noted upon auscultation. Afebrile. No edema noted. No murmurs noted. Capillary
refill <2 seconds bilaterally in fingernails noted. Unable to access capillary refill in toes due to fingernail polish. Brachial and
Radial peripheral pulse +2 noted on right side. Unable to access left side radial pulse due to left hand dorsal IV placement.
INTEGUMENTARY (include wounds): Skin pink, warm & dry. Intact: without rash/lesions. Ecchymosis noted on the shin of lower
right extremity. Purplish discoloration noted. Normal Skin turgor noted. No skin tears/breakdowns noted. Clear, warm, dry, &
intact skin on back noted. No eczema present.
MUSCULOSKELETAL: Full ROM in all extremities present with good movement. Good bilateral Muscle tone. Strong strength bilaterally
equal.
GASTROINTESTINAL: Active bowel sounds present. Soft, non-distended abdomen. No tenderness noted. Peds Clear Liquid diet well
tolerated. 1 bowel movement during my shift.
GENITOURINARY: Voided twice in toilet. Yellow, no odor, no sediment noted. Total output of 120ML during my shift. Unable to access
skin in genital areas.
MEDICATIONS:
Trade Name
Therapeutic effect
Rationale (why)
Potential Side
Nursing Implications: Assess pain prior
Tylenol
Pain and Fever relief post-op
nasolabial fistula repair.
To relieve pain
from nasolabial
fistula repair.
Reduce fever
post-op.
Hepatotoxicity
when does
exceeds
90mg/kg/day.
Skin rash
implicating an
allergic
reaction.
to administration. Administer 7.06mL
PO Q6h. Monitor for potential side
effects, and therapeutic effects.
Reassess pain using.
Drug Class:
Analgesics
Generic Name
Acetaminophen
Calculations: (per dose if
possible)
Have:325mg/10.15mL
226.25mg/7.06mL Desired: 226.25mg
12.5mg/kg(12.5x18.1=226.25)
226.25mg/325mg=0.696
Frequency: Q6h
0.696x10.15mL= 7.06mL
Dose:
Route: PO
Trade Name
Therapeutic effect
Rationale (why)
Potential Side
Effects
Nursing Implications
Drug Class:
Generic Name
Calculations: (per dose if
possible)
Dose:
Frequency:
Route:
LAB DATA & DIAGNOSTIC EVALUATION
Include date: NO LABS
Lab Ordered
Client Values
Normal values
Rationale for this patient:
Nursing Implications:
1)
2)
Lab Ordered
Client Values
Normal values
Rationale for this patient:
Nursing Implications:
1)
2)
Lab Ordered
Client Values
Normal values
Rationale for this patient:
Nursing Implications:
1)
2)
Lab Ordered
Client Values
Normal values
Rationale for this patient:
Nursing Implications:
1)
2)
Lab Ordered
Client Values
Normal values
Rationale for this patient:
Nursing Implications:
1)
2)
DIAGNOSTIC EVALUATION
PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSIS
List two nursing diagnosis relevant to patient condition & based on assessment
1. Pain
2. Risk for Fluid Volume Deficit
NURSING CARE PLAN
A care plan should start with the major issues for that client. Write the top two priority nursing diagnosis for this client, with the highest priority first. Be sure to include “related to”, “as
evidenced by”, or “risk factors” (if at risk diagnosis) for each medical diagnosis. Write a short term and long term expected outcome goal per nursing diagnosis stated in terms of client
achievement - “the client will…”). List at least 3 specific nursing actions (interventions) for each nursing diagnosis and give the scientific rationale for selecting the action you will use to
work toward that goal. BE SURE TO NUMBER EACH INTERVENTION AND CORRESPONDING RATIONALE. INCLUDE PAGE NUMBERS WITH CITATIONS FOR EACH
RATIONALE. REMEMBER: RATIONALE SHOULD NOT CONTAIN WORDS LIKE: THESE, THIS, TO, ETC. THEY MUST DESCRIBE WHY/HOW YOUR INTERVENTION HELP
REACH YOUR GOAL AND MUST BE ABLE TO STAND ALONE AS A STATEMENT.
NURSING CARE PLAN
NURSING DIAGNOSIS
EXPECTED OUTCOME
NURSING INTERVENTIONS (3)
RATIONALE (3)
(NANDA APPROVED)
Short term goal (1)
(What do you plan to do?)
(Why are you doing this?)
(Measurable Goal)
EVALUATION FOR EACH
INTERVENTION AND
SHORT TERM GOAL
Long term goal (1)
Risk for Fluid Volume
Deficit
Patient will consume
240mL liquids PO during
shift.
Patient will show no signs
and symptoms of Fluid
Volume Deficit.
NURSING DIAGNOSIS
EXPECTED OUTCOME
Short term goal (1)
(Measurable Goal)
Long term goal (1
The nurse will encourage and provide
intake of liquids PO during shift.
To ensure patient has
hydration appropriate for
age.
The patient did not consume
240 ml of liquid during my
shift.
The nurse will monitor and document
intake and output Q2h.
To ensure patient has
adequate intake and output
to prevent FVD.
The total intake was 0mL and
total output was 120mL
during my shift.
Increased Heart rate,
increased respirations, and
decreased respirations are
positive signs of Fluid
Volume Deficit.
The vital signs were
monitored documented at
2141: BP 87/52, T 97.3
Auxiliary Pulse 73 RR 24 O2
sat 98% on Room Air, Pain
Assessed at 1807 (rFlacc) 7,
assessed at 1907 (rFlacc) 0.
The nurse will monitor and document BP,
Respirations, and HR Q4h.
NURSING INTERVENTIONS (3)
RATIONALE (3)
(Why are you doing this?)
EVALUATION FOR EACH
INTERVENTION (3) AND
SHORT TERM GOAL (1)
Reference List (APA)
Acetaminophen. Lexicomp. Wolters Kluwer Health, Inc.; 2022. Updated September 1, 2022.
Accessed July 1, 2023. https://online.lexi.com
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Care Plan Grading Matrix
Student: ________________ Clinical site___________ Date_________
Instructor_____________________
Section
Possible Points
Name (student/pt initials), Date, Age, Pain score, HPI, PMH,
Current Orders, Developmental Assessment
10
Physical Assessment
20
Medication
10
Demographic Data
Lab & Diagnostic Evaluation
5
Medical Diagnosis
5
List of Prioritized Nursing Diagnosis One-part statements
5
Nursing Care Plan
(Dx statements 3 part statements– minimum of 3, Goals –
short & long term, Interventions – minimum of 3, Rationales – 1
for each intervention, Evaluation)
35
Med and Lab References & APA format
10
Spelling/ Grammar and Submission
Total
100
[10]
Score
Notes:
[11]