N450 Pediatric & Child Health Care Nursing Theory & Clinical
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HOSPITAL CARE PLANNING
FORMS
Harding University College of Nursing
2004-2005
N450 Pediatric & Child Health Care Nursing Theory & Clinical
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N450 WEEKLY NURSING ANALYSIS OF NEEDS
Student Name
Date
Client Initials
Age
Unit
Vital Signs
Normal T
Client T
P
P
R
BP
Wt.
lbs.
kg. Ht.
.
R
BP
Wt.
lbs.
kg. Ht.
.
Hydration and Nutritional Status
Expected Nutritional Needs
#
cal/day
Calculate Formula Feed
Diet Order/Route
(Br/Formula
Client 24th Diet Consumed
cal/oz)
Tolerated
Calculate expected 24 hr Maintenance Fluid
=
Current IV Fluid:
Current IV Rate:
Calculate expected 24 hr urine output
Last 24 hr Fluid Intake
cc/day
cc/day
cc/Output
cc/Stool
Analyze hydration status: expected I&O with 24 hr totals
Psycho/social/spiritual Development
Erik Erikson - Expected developmental stage and behaviors:
Actual stage client is in?
List behaviors
What developmental stage is family member in?
List behaviors
Piaget – Expected stage and behaviors
Actual stage client is in?
List behaviors
Maslow - List primary needs
Harding University College of Nursing
2004-2005
N450 Pediatric & Child Health Care Nursing Theory & Clinical
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Physical Development
Normal Language
Client
Normal Social/Play
Client
Normal Fine Motor
Client
Normal Gross Motor
Client
Anticipated Sleep Needs ________________Client Sleep Pattern
Analysis of Development (Summarize the previous two sections)
Summary of Developmental Status & Needs
Family Information
Parents work information
Where does family live? (Distance from hospital)
How often can/does the family visit?
Does the family have transportation to the hospital?
How many other children are in the family?
Identify cultural needs
Caregiver/parents needs
Summary of Family Needs
Harding University College of Nursing
2004-2005
N450 Pediatric & Child Health Care Nursing Theory & Clinical
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WEEKLY TEACHING
Circle: Client/Family/Both (titles)
Resources Used
1. What did the client/family want to learn/to know more about?
2. Identify how you incorporated relevant teaching/learning principles.
3. Identify how you adapted your teaching based on cultural needs.
4. Describe your teaching session.
5. Evaluate the child and/or family’s response to your teaching.
6. What follow-up teaching is needed?
7. What did you learn from this?
WEEKLY PLAY
1. What did the child want play or do?
2. Describe your play session. What did you do?
3. Describe the child’s and family member’s response.
4. What did you learn from this?
Harding University College of Nursing
2004-2005
N450 Pediatric & Child Health Care Nursing Theory & Clinical
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Name:
Date:
N450 CARE PLANNING FORM:
FOCUSING ON CHILD/FAMILY HEALTH TO ENHANCE WELL-BEING
Directions: Ask the child and parent the questions beginning on next page. Place their exact
words/responses in quotation marks. When a child cannot speak, ask the child the question in
your mind or out loud and write down the response you hear in your mind. Use [brackets] to
specify this type of response. Note you do not need to ask the questions in this order nor do you
need to ask all the questions at one time but rather let the information flow in a healthy,
productive way.
Assessment
General Information:
Child’s Initials:
Age:
Reason(s) for hospitalization:
Family member’s Initials:
Length of Stay:
Relationship:
Date of Last Visit:
Brief History of Situation (A summary of child and family’s situation and summary of
hospitalization)
Disease pathophysiology and medical treatment (Attach disease/treatment information from a
website. Highlight the significant information as it relates to your child.)
Harding University College of Nursing
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Description of Situation: As stated by the child & family member
1. Ask questions like “Can you tell me how you see your situation.” “What do you think has
caused this to occur?” “What do you think will improve the situation?”
A. Description of situation from child’s perspective.
B. Description of situation from family member’ s perspective.
2. “What have you been thinking about today?” “What concerns you most at this time?”
Child
Family Member
3.
“What is the most important thing you would like for me to do for you today?”
Child
Family member
4.
“What would you like to know more about?” (Identifies teaching needs)
Child
Family member
Harding University College of Nursing
2004-2005
N450 Pediatric & Child Health Care Nursing Theory & Clinical
Expectations
5. "What would you like to see happen today?"
Child
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“What is important to you at this time?”
Family Member
6. "What do you think will happen while you are in the hospital?"
Child
Resource Potential
7.“Who helps you to feel better?”
Child
“What do they do?”
Child
"Who do you usually talk things over with?”
Family Member
"Are they available to you while are here?”
Family Member
Discharge Planning
7. Ask Parents “What needs do foresee in taking your child home?
8. What additional needs do you anticipate for this child and family?
Anticipated Discharge Needs
Anticipated Teaching Needs
Anticipated Referrals
Harding University College of Nursing
2004-2005
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Nursing Analysis
1. Describe the Adaptive Potential (APAM) state and cite specific behaviors for:
Child
Family Member
2. How is this hospitalization affecting the child and family member?
Child
Family Member
3. How has the child and parent rated the child’s pain? List the specific comfort interventions
have been done including the time and type of intervention and the child’s response.
4. Describe congruence or lack of between what the child and family member has said and nonverbal data?
Child
Family Member
5. Does the child or family member need help interacting with health team members? If so
describe need.
Child
Family Member
6. Describe internal strengths each one possesses to handle this situation.
Child
Family Member
7. List all the primary needs or concerns identified above for:
Child
Family Member
Harding University College of Nursing
2004-2005
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Concept Map
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2004-2005
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Care Map
Problem:
General Client Goal:
Outcomes:
Nursing Interventions
Client Responses
Impressions:
Harding University College of Nursing
2004-2005
N450 Pediatric & Child Health Nursing Theory & Clinical
Nursing Interventions
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Client Responses
Impressions:
Harding University College of Nursing
2004-2005
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Evaluation
1. Describe how your relationship with this child and family developed.
2. Describe how the care you gave met the child and family member(s) needs, concerns,
facilitated self-care resources and encouraged strengths.
Child
Family Member
3. What did you gain from your interaction with this client/family?
4. Suggestions for future care of this child and family.
Harding University College of Nursing