Henry Ford Community College Student=s Name:_Man Le________________________ Client=s Initials:__RB________________________

MINI ASSESSMENT GUIDE Diagnosis: Vomiting, Dyhydration_________ Age: _13 yrs old_____________________ Clinical Week: ___1_______ Nursing System: Partially Compensatory Date: _1-17-12 _ Orem=s Self Care Deficit: Dehydration due to decrease intake, loss of fluids with vomiting Developmental Assessment
Immunizations (Include norm for age and what child has had): No immunization on file. Stated immunizations were up to date

Physiological Assessment
Nurse=s Initial Impression [Verbal picture of child and DCA(s)]: Was underneath covers lying in hospital bed and mom was lying on the other hospitals bed. When approached to do vitals, he was cooperative and mom was willing to give information. Full Term _X_____ Premature ______ (as appropriate)

Psychosocial Assessment [Include DCA(s)]

National Origin: White/ Caucasian Religious/Spiritual Beliefs: Catholic DCA(s):`Mom and Dad Siblings: 2 sisters Sex: Male Age: 13 yr old Siblings: 2 sisters Sex: females Age: unknown/ older sisters Insurance: INS Plan Any Financial Concerns: Parents are married and reside with one another. Mom is a nurse, Dad is working also (unknown profession) Erickson=s Stage of Psychosocial Development (include reason for selection of specific developmental stage): Sense of identity vs alienation. I believe the patient is at this appropriate stage. Always have his cell phone wherever he goes waiting for phone calls from peers. Missed playing basketball with friends. .

Weight 115 lbs______ Percentile for age ________ Height 5 6______ Percentile for age ________

Complete pediatric assessment: Neuro: A&0x3. No pain, Afebrile temp 97.5 F Cardiac: 114/64 Apical HR 65. No sign of edema, Brisk cap refill. All peripheral pulses are palpable, regular rhythm & strong. Resp: 16 bpm. Lungs CTA, breathe even and unlabored. 02 status 96%. No SOB @ rest GI/GU: BRP, Bowel sound present, stated had BM earlier. Urine is yellow. Patient is on clear liquid diet. Moist mucus membranes. All teeth are present. No cavities noted. Musculoskeletal: Patient walked to bathroom with moms assisted. Gait is steady. No lack of coordination Skin: Intact over bony prominences, Labs: Na 141, K 4, chloride 106, carbon dioxide 23, wbc $ 11.4, rbc 5.55, hemo 16.2, hemat 44.4 d5 L arm

Norms for age (include cognitive, gross motor and fine motor, developmental milestones) and compare your findings with normals for age. TEXTBOOK CHILD=S

Textbook : sexual maturation, physical growth spurt, compares self with others, wide mood swings, abstract thinking Home environment: Is it safe for developmental age? Home environment: The patient resides with mother and father. Stated that neighborhood is safe. He is active and involved in sports. DCA is a nurse and seemed educated on the dangers on middle childhood. Smoke detectors in home. Guns are present but locked and unloaded Child: Patient is able to think beyond present. Stated what he would do when discharged. He is 13 yr old: height 56 and weight 115lbs. He likes to play basketball with friends. Patient is cooperative and jokes occasionally with mom. Always have his cellphone by his side.

Special needs of child (i.e., braces, tube feeding, central lines)

Nsg 250 PEDS

SELF CARE DEFICIT

NURSING DIAGNOSIS
NANDA: Related to: Subjective data: Client-Centered Outcome with Indicators:

PLANNING
Therapeutic Nursing Interventions: Scientific Rationale for each Intervention:

IMPLEMENTATION
Implementation:

EVALUATION
Evaluation of outcome:

Objective data: Revisions:

DATA SUPPORTS NSG DX AND IS COMPLETE

Outcome STATEMENT is related to NSG DX. Outcome STATEMENT includes: who, what, condition, when, how Indicators are: -realistic/measurable -attainable within time available -related to client data and stated outcome

THERAPEUTIC INTERVENTIONS are based on identified outcome. INCLUDE: -action to be performed -descriptive phrase - time/how often -congruent with other therapies

Scientific Rationale: -Documented from published source with APA -reflects understanding of intervention -reflects client data

Identify what was actually done for each therapeutic nursing intervention. Identify which interventions were not implemented.

Evaluate each to determine if outcome was met: completely, partially, not at all States revisions planned based on evaluation of indicator

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