Pediatric Worksheet

Student: Priority Assessments: Age: Wt: Client (first, l.):

Date: Diet: MR #
Nurse: Activity: Room #
Allergies:
Med Order Time Notes
Dx:
PMH:
IV Assessment:  expiration tags  3mL extra in volutrol
 right solution ________  empty @ __________  drip chamber
 right rate ___________  top clamp closed  fluid
 site condition _______  volutrol open  white peak

Teaching:
Play:
Treatments / Procedures / RT / Notes
0630—0700:  meds;
0700—0800:  I.V.; chart vs;
0800—0900:  I.V.;
0900—1000:  I.V.;
1000—1100:  I.V.;
1100—1200:  I.V.; chart vs;
1200—1300:  I.V.; final charting;

Call H.O. if T > ______, SpO2 < ______%, HR > ______ or < ______, RR > ______ or <
______, SBP > ______ or < ______, DBP > ______ or < ______, UOP < __________ .

Input: Vitals 08:00 12:00

Labs:
Temp
t
Hc

HR
RB
BC
b
C

RR
Hg
W

BrSnd
Glucose Platelets Output: Sp O2
Na+ Cl- BUN Hgb O2
K+ CO2 Creat Hct BowSnd
WBC BP