Pediatric Nursing Care Plans

Pediatric Nursing Care Plans Author Sharon Ennis Axton
ISBN-10 013098969X
Release 2003
Pages 371
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The goal ofPediatric Care Plansis to assist practicing nurses, nurse educators, and students in implementing the nursing process for pediatric patients. This book provides a quick reference for correlating frequently encountered pediatric medical diagnoses with nursing diagnoses. Most of the nursing diagnoses are those accepted by the North American Nursing Diagnosis Association (NANDA). On a few occasions, it was necessary to use nursing diagnoses that are not on the NANDA list. These are identified by asterisks. A special feature of this book is the discharge planning incorporated into each care plan, identified by the house logo. Each diagnostic entry has a standard set of components: MEDICAL DIAGNOSIS. PATHOPHYSIOLOGY.This is a basic and brief overview of the pathophysiology of the medical diagnosis. PRIMARY NURSING DIAGNOSIS.This can be stated as either actual or at risk for occurring. The nurse writing the care plan makes the determination. DEFINITION.This refers only to the nursing diagnosis and not to the medical diagnosis. POSSIBLY RELATED TO.The rationale for the selection of each nursing diagnosis is inherent in this statement. CHARACTERISTICS.These are of the selected nursing diagnosis and of the identified medical diagnosis. The list presents possible signs and symptoms specific to the identified nursing and medical diagnoses. EXPECTED OUTCOMES.Listing expected outcomes is the next step in the nursing process after identification of the nursing diagnosis. Expected outcomes may be listed on a nursing care plan as patient goals or objectives. Outcomes are written as specifically as possible so that they can be measured and easily evaluated. Directions are sometimes included to help individualize the expected outcomes for each infant/child. For example, Expected Outcomes might read as follows: Child will have adequate cardiac output as evidenced by heart rate within acceptable range (state specific highest and lowest rates for each child). To individualize this statement, the nurse needs to include the highest and lowest acceptable heart rates for each child. The range will vary depending upon the child's age and disease state. The expected outcome for a 1-month-old infant with normal cardiac function would read: Infant will have adequate cardiac output as evidenced by heart rate of 100 to 160 beats/minute. POSSIBLE NURSING INTERVENTIONS.These are ways in which the nurse can assist the infant/child and/or family to achieve the expected outcomes. Some of these interventions areindependentnursing actions, whereas others arecollaborative(the nurse implements the physician's orders). For example, a nursing intervention to "elevate head of bed at 30° angle" could be instituted for an infant or child with increased intracranial pressure without a specific order from the physician. This would be an independent nursing intervention. A nursing intervention to "administer antibiotic on schedule" depends upon the physician's order. EVALUATION FOR CHARTING.This section, which deals with the final step in the nursing process, evaluates the expected outcomes and, to some extent, the identified nursing interventions. Statements made here direct the reader to describe or state results. For example, the reader may be directed to "describe breath sounds." This would be correlated with the expected outcome "infant/child will have clear and equal breath sounds" and with a nursing intervention such as "assess and record breath sounds every 4 hours and PM." Evaluation is an ongoing process; the evaluation statement may need to be changed frequently. For this reason, the nurse may wish to include this part of the nursing process in the daily charting, noting on the nursing care plan under the evaluation column "see nurses' notes," stating the date and time, and initialing the note. This section includes documentation for all appropriate forms, such as flowsheets, graphic sheets, or nurses' notes. NURSING DIAGNOSES.Following the primary nursing diagnosis are one to two associated nursing diagnoses that are prioritized and carried through the nursing process. The nurse writing the care plan decides if these are actual nursing diagnoses or if the patient is at risk for the selected nursing diagnoses. RELATED NURSING DIAGNOSES.These are nursing diagnoses that are most likely to be included in a nursing care plan for an infant or child with the stated medical diagnosis. Many of these nursing diagnoses are actual; the patient is at risk for others. The nurse determines which. The related nursing diagnoses are in priority order for an infant/child with the stated medical diagnosis. However, the needs and condition of the infant or child will determine whether the nurse must reorder the priorities. All related nursing diagnoses are completely developed through the nursing process and can be found in the text; refer to the index for location. To use this book most efficiently, scan the Table of Contents for the applicable medical diagnosis. After finding it in the text, review the accompanying nursing care plan and related nursing diagnoses and select the appropriate expected outcomes and nursing interventions. Write those on the nursing care plan and then implement them. Later, at intervals that you designate when writing the care plan, evaluate the infant's or child's response to your nursing interventions and record your findings.