Examples of Data Forms

 

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Copyright 2004

 

Physical Assessment   Examples Examples
Child / Family Development   Nursing Diagnosis # 1 Cultural assessment
Clinical Manifestations   Nursing Diagnosis #2 Spiritual Assessment
Discharge Needs   Nursing Diagnosis #3  
       

 

Physical Assessment

NEUROLOGICAL: (Describe how assessed. Do not put normal)

 Examples of neurological assessment on a 16 month old

Fontanels closed, anterior fontanel slightly hard, and flat, assessed by palpation____________________

 

Level of consciousness, alert, orientation, memory _awake, alert, and happy. Pt. was asked who is that and he replied with “Mom”.        

Pediatric Eye Response _4-open spontaneous, pt. looking around the room. at mother and at nurse______

Pediatric Motor Response 6-obeys to command, pt was able to give nurse high-five when asked too._____  

Pediatric Verbal Response  5-responsive, pt. said “Mom” when asked who is that, and nose when nurse touched his nose and said what is that.                                                                                                              

Pediatric Total Coma Scale __15 points____________________________________________________

Speech _clear, was able to say about 6 words and used gestures to make needs known_______

Sensory Pt was very ticklish on his feet and abdomen                                                                                                

Motor _pt walked by himself, was able to throw a ball to his mom, and scribble on a piece of paper  

Vision _pt. does not wear glasses, and was able to see the nurse who was standing 3 feet away point to her eyes, and the pt. imitated her.                                                                                                                                               

Hearing _pt.’s mom stated that pt. passed all his hearing test without problems, and he was able to hear the television without problems________________________________                                                                    

Reflexes pt. was startled when the ball was thrown back to him and he was not looking.      .                              

 

Child / Family Development

1.         Child / Family developmental phase: family theorist of choice:

  • The patient and his family are in Duvall’s Stage 3: families with preschool children. The third stage of the family life cycle commences when the firstborn child is about 21/2 years old and terminates when he or she is 5 years old. The family is becoming complex and differentiated. Family life is busy and demanding for the parents (Friedman, Bowden & Jones, 2003, p. 218-220). T.K. and is family belong to this category because T.K.’s brother is 5 years old, and in preschool. He began attending a Lutheran preschool about 1 year ago. The patient’s mother stated that her oldest son really enjoys it, and it has been really good for him to meet new friends. But she said at times it is hard because T.K. does not understand why he can not go to school with his bother. She stated that he cries and gets all upset when they drop him off at school. But then she said it has also been nice because it gives her the ability to spend some alone time with T.K. She then claimed that the preschool stage has not been that demanding on her and her husband because she is a stay at home Mom so she does not have to worry about trying to work with his school schedule and her work schedule. Also her husband’s job is flexible which helps out a lot.

 

Spiritual Assessment Tool: Sample

 

Spiritual Assessment Tool

 

1. Belief System

T.K.’s mother stated that they belong to a Christian group, and attended a Christian church, but are not involved in a bible study or small personal group. There oldest son attends preschool at the church they attended.

 

2. Ethics and values

The patient’s mother stated that her family values honesty and love. She stated that they tell their children all the time that it is important to be nice to others and not to lie or be dishonest. She feels that if her boys could just remember to be truthful, nice, and loving that they will be great men and someday make wonderful husbands.

 

3. Lifestyle

No, T.K.’s family does not observe any dietary restrictions. They do hold hands and pray before every meal. The patient’s mother stated that sometimes if there is something really bothering to the family they will get together and pray about. She stated that they have taught there children that before they fall asleep at night that they should talk to God and thank him for all the wonderful things He has given them.

 

4. Involvement in a spiritual community

T.K.’s mother stated that they were not involved in any community act ivies, but most likely they will be when there children get older and are involved in sports. No their family does not belong to any spiritual or support groups. T.K.’s father is involved in a Social Service group called “The Guardian Angels” which helps need children and takes them to the movies, baseball games, and fun things that the children’s parents cannot afford to do.

 

5. Education

Yes, T.K.’s older brother attends a Lutheran preschool 3 days a week for a half a day. No, nobody in their family receives religious instruction except what her son learns at school. The patient’s mother stated that she wants her children to be understanding of other people religion and beliefs. She wants her children to know that Jesus Christ died for them and that He will always love him and give forgiveness. This should be incorporated into T.K.’s health care by showing him love and forgiveness, even if he did spit out all of his medicine (ha ha).

 

6. Future events

In the future when T.K. is old enough to understand she will talk to him about sex. She will inform him that he should wait until his married, but if he does not then he should use condoms. She feels that an abortion is not the right thing to do, but that it should be the women’s choice what she does with her body, and nobody else’s choice. She believes that blood transfusions are fine, and that when a person dies they go to Heaven.

 

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Cultural Assessment Tool 

Cultural Influence

 

Cultural Assessment Tool

  • What is the attitude towards preventive health measures such as immunizations?

T.K.’s mother thinks that it is important for her children to get all of their immunizations, and on time so that they work properly. But she did state that sometimes she gets worried because she has heard about all of these normal healthy kids getting Autism for the immunizations. This worries her, but she feels that her children are more like to get sick from not having the immunization then from getting the immunization.

  • Is there a person in the family responsible for various health related decisions, such as where to go, whom to see, and what advice to follow?

The patient’s mother stated that she is the one who makes all the medical decisions; unless it is something really big and important then they will have to make that decision together. For example, she had to take fertility drugs to get pregnant with her first son. They decided together that she would not take any more and that if she got pregnant with a second child it would be because that’s what God wanted, and not because she took a pill.

  • In religious practices is baptism of the child as an infant an important ritual / practice?

T.K.’s mother stated that baptizing her children was not really important to her and her husband. They feel that if there children want to be Christian then they can make that decision for themselves, but they was not going to tell them what religion they had to be.

  • What language is spoken in the home?

English

  • How well does the patient understand English, both spoken and written? 

Very well, it is the only language they know and speak.

  • Is an interpreter needed?

No

  • Who makes the decisions in the family?

T.K.’s mother stated that she makes most of the decisions because she handles all the family finances, and takes care of the children, and family events.

  • What is the composition of the family, how many generations are considered to be a single family, and which relatives compose the family unit?

The patient’s mother stated that they are very close with all of there family, and they consider all of there family (grandparents, uncles/aunts, cousins) first degree family. They were even very close with her grandmother (T.K.’s great-grandmother) until she passed away 5 months ago. She stated that he oldest son was very upset by this because he was really close with her.

  • When do children need to be disciplined or punished, and how is this done (if physical means are used, in what way)?

The patient’s mother stated that children need to be disciplined constantly, “from the second they wake up, to the second they go to bed”. This is done by taking away toys, putting them in time out, and occasionally when her oldest is really bad, by spanking on the bottom. But she feels that the child has to be old enough to understand what he did wrong in order to spank them.

  • Do the parents demonstrate physical affection toward their children and each other?

Yes, T.K.’s mother was very affectionate with T.K. She was kissing him and hugging him when I first walked into the room. She stated that she feels like she cannot hug and kiss her children enough. She also claims that her and her husband hold hands and kiss in front of her children because they want them to know that it is good to be affectionate with each people they love.

  • What major events are important to the family, and how are they celebrated?

All holidays, birthdays and parties are important in their family. They like to make a big deal out of every birthday and have big parties with friends and lots of family. All major holidays are celebrated with all the family, and it is a big event! They cook, dance, talk, and have a wonderful time.

 

 

 

 

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Clinical Manifestations of Current Admission:

According to Text Day of Admission Day of Care
Presenting Signs and Symptoms:                  (3 month old )
  • tachypnia
  • rales
  • infiltration on chest x-ray
  • cough
  • irritable and difficult to console
  • decreased oxygen saturation levels

Viral Pneumonia:

  • low-grade fever
  • rhinorrhea
  • cyanosis
  • grunting respirations
  • retractions
  • coarse crackles/wheezing
  • respiratory distress

Bacterial Pneumonia:

  • fever, tachypnea
  • poor oral intake
  • dehydration
  • productive cough with thick green/yellow/blood-tinged sputum.

(Bowden, 1998, pp 927-933)

  • Nasal congestion

  • Respiratory rate 60+ with grunting and nasal flaring.

  • Oxygen saturation 92 to 94% on room air

  • Wheezing and crackles heard in left lower lobe. 

  • Course non-productive cough.

  • Axillary temperature 99.5

  • Moist mucous membranes, good skin turgor, wet diaper noted on admission. 

 

Subjective Data per mother.

Poor fluid intake

Decrease urine output, number of diapers changes.

Mother states the infant is sleeping more than normal and is irritable when awake.

 

 

Diagnostic Tests:

 

Chest x-ray done on admission

CBC with Diff.

 

 

MD and nursing notes

Respiratory Assessment:
  • tachypnea: 40 to 60 per min
  • tachycardia: HR 175
  • Oxygen saturations: 90 to 96% on 1/2 L of oxygen
  • Crackles heard in RLL
  • no accessory muscles used with respirations

General Assessment:

  • Temperature 99.4 ax
  • Skin warm and pink, good skin turgor.
  • Mucous membranes moist
  • IV fluids at 20 cc/hr
  • PO intake 120 cc of formula at 0800 and 1200.
  • Wet diaper x 3 for 320 cc.s
  • Slept most of the day except for feeding. 

Subjective Data:

Mother states the baby looks better to me today. She is eating better and smiles at her

Diagnostic Information:

Chest x-ray reveals patchy infiltrates in RLL.

CBC indicates elevated WBC count to 12.7

 

 

 

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Discharge Needs

List Educational Needs for caretaker /child

 

  1. Medication
  2. Diet
  3. Activity
  4. Nebulizer use
  5. To monitor for worsening condition
  6. Cough suppressant
  7. Bulb syringe for oral and nasal suctioning
  8. CPR for infants and children

Teaching methods used: (be specific about the discharge plan even if some else will discharge patient)

 

1. -Written and verbal instruction on what the antibiotic is, what it does, how it works, and side effects it may cause.

-Verbal instruction on how important it is to complete the full course of antibiotic therapy, and not to stop it even if T.K. fills better in order to prevent antibiotic resistance and to facilitate complete recovery.

2.-Verbal instruction on how important it is for T.K. to drink lots of juice and water in order to prevent dehydration and liquefy sputum.

-Written and verbal instruction on the importance of the food pyramid and maintaining a balanced diet to maintain T.K.’s health. (Diagram of food pyramid provided)

-Verbal instruction on the importance of a high protein diet, and how it is essential in the role of healing.

-Verbal instruction discussing the importance of small frequent meals to conserve energy during the acute phase of healing.

3. –Verbal and written instruction stating that T.K. should get lots of rest, even if he feels better don’t let him over do it.

-Verbal instruction that T.K. may be weak and fatigue for weeks after the infection, and gradual return to normal actives is important.

4. –Verbal, written, and demonstration on how to use the albuterol nebulizer, and to use it if she hears T.K. wheezing or having difficulty breathing. She should also use it a night before T.K. falls asleep for approx. 1 week.

5.- Verbal and written instruction that states signs of respiratory distress (increased breathing, blue lips, grunting, nasal flaring)

-Verbal instruction to return to the ER if cough, fever, shortness of breath worsen or do not improve.

6. Verbal instruction not to use a cough suppressant if a productive cough present, because the cough will help T.K. to get the secretions out of his lungs, in return making him better.

7. Verbal and demonstration on bulb suction and insertion of normal saline into nares to loosen dried secretions.

8. Video on CPR

Evaluation and modification of teaching:

1.      Mother stated what the antibiotic was, and that she was going to give it once a day for 3 days. Mother stated that she was to make that her son drank lots of juice and water, are small meals high in protein, and she refereed to the handout for the food pyramid.

2.      Mother stated that she would be sure that T.K. got lots of rest and that she would not let him over tire himself.

3.      Mother stated that she already knows how to use a nebulizer because her other son at home has one for his pneumonia. She explained how she would use it, and that she would use it for any signs of increased breathing.

4.      Mother named 3 signs of respiratory distress and referred to the handout for the others. She also stated that she would bring him back to the ER if she saw any of the signs.

5.      Mother stated that she would not give T.K. any cough syrup because that is a sign that he is getting better if he coughs up secretions.

6.      Mother demonstrated the use of the bulb syringe and saline drops on T.K. and had no questions or concerns.

7.      Mother watched video on CPR and stated that it was a good refresher to her because she had forgotten a lot of the things.

 

Medications / treatments/ equipment needed at time of discharge

  1. Zithromax 60 mg PO everyday for 3 days.
  2. Albuterol 0.5 cc in 2cc of NS as needed for wheezing
  3. Bulb syringe and saline nasal drops

Do they know how to administer the medication and where to fill the prescription?

Mother stated that she would give the medicine once a day for 3 days. She will fill the prescription at her father-in-laws pharmacy.

 

Do they know how to administer any treatments?

Mother stated that she would draw up 1.5 cc into an oral syringe and squirt it into the pocket of his check.

Do they have the equipment needed?

Mother stated that she already has a nebulizer at home for T.K. to use. She was given a bulb syringe and saline drops and knows that she can by them over the counter at any store if she needs more.

 Thanks to K. Walker 2003

 

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Nursing Diagnosis:  #1

 

PLEASE REMEMBER ON YOUR DATA FORMS YOU NEED RATIONAL FOR YOUR NURSING INTERVENTIONS AND RATIONAL MUST BE BACKED UP BY A JOURNAL ARTICLE OR AMERICAN ACADEMY OF PEDIATRICS POSITION STATEMENT - USE OF TEXT BOOK NOT ACCEPTABLE

 

Nursing Diagnosis: Anxiety r/t hospitalization and unknown etiology of illness of their child as manifested by the patient's mother stating, "I am nervous, we are still waiting for the results of the tests that were done on admission. We still do not know what is causing our child's breathing problems."

Patient / parent Objectives:

  • Family members (mother) will be able to verbalize decreased feelings of anxiety about child's illness by the end of the shift.
  • Parents will state that they received accurate information regarding diagnostic tests done on their child.
  • Mother will be allowed to rest and shower no later than 1400 today.

Nursing Interventions:

  1. Nurse will assess mothers level of anxiety by asking open ended questions about her concerns.
  2. Mother will be encouraged to ask questions about infants condition and care.
  3. The nurse will offer the mother breakfast in the room.
  4. The nurse will offer to have volunteer watch infant while mother goes to cafeteria for breakfast and takes a shower.
  5. The nurse will arrange for social services to visit her to answer questions about the insurance coverage for hospital visit, and available community resources.
  6. The nurse will have house physician talk to the family about results of the diagnostic tests as they become available.
  7. The nurse will give positive reinforcement to the mother for her care of the infant.

Evaluation of Interventions:

  1. Mother was very open about her concerns. She was appreciative of the time I spent listening and talking to her.
  2. Mother had questions about suctioning the baby with the bulb syringe and the CPT being done by the respiratory therapy.
  3. Mother ate breakfast in room, she did not want to leave the baby.
  4. Mother stated that her mother would be coming at 1100 to sit with the infant so she could go home to shower and change her clothing. Mother went home for 3 hours. 
  5. Social services talked to mother about insurance coverage.
  6. Physician discussed laboratory results with the parents and projected discharge date. 
  7. Mother appreciated the comments about her care of the infant. This is her first baby and she was nervous about feeding and caring for the infant with the oxygen on. 

Modification to Plan:  I would teach the mother / family more about the pulse oximeter monitoring and the treatment being done by the respiratory therapist. I had her demonstrate how to instill saline nose drops and bulb suctioning. I explained to her how the CPT was loosening the secretions in the babies lungs and how to do CPT at home. The information seemed to give the mother more control over the child's treatment and reduce her anxiety.

 

Based on modification of plan by M.Tsiorba on a 3 month old infant with pneumonia

 

Nursing Diagnosis Example: #2

1. Key assessment facts for Nursing Diagnosis 1 / Collaborative problem

Mother was over reactive: spoke loudly, fast and harshly to nurse

Mother states quilt and concern about 3 children at home. Grandmother also, high strung: talking sternly about minimal issues.

Nursing Diagnosis: #! Care giver role strain

 

Patient goals or outcomes

1. Mother and grandmother will state understanding of disease process and normal symptoms to expect by end of shift.

2. Mother will take a break and go home to rest and spend time with other children.

 

Nursing / Health Care Interventions

Rationale

  1. Nurse will assess what mother / grandmother know about the child’s condition.
  2. Nurse will review expected signs and symptoms.
  3. Nurse will explain reason for INH treatments and suctioning.
  4. Nurse will build trust with the mother by listening, presenting information and clarification of information as needed.
  5. Nurse will encourage mother to go home for two hours in the afternoon after the baby if feed.
  6. Nurse will assure the mother she will sit in the room with the baby or have the volunteer sit in the room, so the baby is not left along.
  7. Hospital phone number and name of student and primary nurse is given to mom so she can call back if she has a concern.

 

 

 

“Respiratory distress or air hunger creates anxiety in both infants and parents.” (Bowden p. 923)

 

“Children with bronchiolitis are often admitted due to poor fluid intake and respiratory distress. Sign and symptoms need to be assessed to determine if child is doing better.” (Anderson, 2000)

 

Hospital procedures and routines can be overwhelming to a child / family. Adequate preparation and explanation of routines and procedures can help reduce anxiety. (Bowden Procedure Manuel, 2002)

 

“Parents are often suffering from frustration and worry about the child’s condition, as well as being completely exhausted at the time of admission” (Bowden, 1998)

“Parents of children with respiratory illness need to express their feelings and receive support. Nurses or social service personnel are the ideal people to provide there interventions.” (Anderson 2000)

Evaluation of each Intervention

Modifications Potential or Actual

  1. Family did not want to listen to the nurse they “knew” everything.
  2. Family did ask questions when I was assessing the infants respirations and taking the temperature.
  3. Despite the nurses explanation about the procedures and treatments the mother and grandmother remained anxious and stressed over the INH treatments and suctioning
  4. Mother continued to ask for the doctor to come in and see the baby.
  5. In the afternoon the mother did go home for 2 hours after I promised that the baby would not be left alone.
  6. The mother did not call the hospital while I was there.

I felt I did develop some trust with the family when the mom agreed to go home for awhile. She was concerned that the nurses were avoiding her and the baby. Although she wanted the baby to sleep, once it was explained why we had to suction the baby and do the breathing treatments she seemed to understand, even though she remained a little anxious.

I would have like to give written information about the diagnosis and treatments so the mother / grandmother could look at it.

 

Although I could not stay in the room the whole time the mother was gone, I asked one of the volunteers to sit with the baby and checked on the baby every 15 minutes.

 

 

Nursing Diagnosis Example: #3

Patient assessment at 0745 revealed coarse breath sounds bilaterally, with wheezes and crackles, nasal congestion, and intercostals retractions.  Oxygen saturation of ½ liter oxygen 96 to 99%.

Ineffective breathing pattern

Patient goals or outcomes

Infant will demonstrate improved breathing pattern (decreased retractions, decreased wheezing and decreased cough in 12 hours)

Infant will maintain oxygen saturation of 96 to 100% on room air within 12 hours.

 

Nursing / Health Care Interventions

Rationale

  1. Nurse will assess breath sounds q 4 hours and before and after suctioning.
  2. Nurse will deep suction prn
  3. Nurse will coordinate care with respiratory therapy.
  4. Nurse will teach parent the reason for the IMH therapy and suctioning
  5. Oxygen will be regulated to maintain oxygen saturation at 96 to 100%.
  6. Head of bed will be elevated.

 

 

 

 

 

According to hospital procedure patients are assessed every four hours and lungs are auscultated before and after deep suctioning. (HMH procedure manual)

“Minimizing energy expenditure and oxygen consumption should remain a primary goal of therapy until the child’s oxygen saturations are continuously with normal limits.” (Bowden, 1998, p923)

       Despite controversy in the treatment of RSV bronchiolitis bronchodilators and deep suctioning are still a standard of care and can help the infant from progressing to respiratory failure. (Anderson, 2000)

  “Oxygen should be administered to infants with all but the mildest cases of bronchiolitis.” (Bowden, 1998, p 921)

  “Positioning the bed in an elevated position provided comfort and facilitates removal of secretions.” (Bowden Procedure Manual 2002)

Evaluation of each Intervention

Modifications Potential or Actual

  1. Lungs were assessed at 0800 and 1200 and before and after suctioning with no difference from described above.
  2. Infant was suctioned twice during my shift after INH treatments for a small amount of thick green mucous.
  3. RT did treatments before feeds so the infant could suck better and retain feedings.
  4. Oxygen was maintained at ½ liter for the shift with oxygen saturation range of 94 to 99%.
  5. Infant was maintained with HOB elevated.

The intervention are well documented standards of care. The only other medication that may be initiated, especially in the premature infant is Rivaviron. This was not given to my patient since she did not meet the criteria.

  The physician did want us to try to wean the baby off the oxygen in the next 12 hours.

Infant will not be kept in the hospital until the AM and re-evaluated at that time.

 

 

Evaluation of Goals / Outcomes

Modifications Potential or Actual

The baby did demonstrate decreased work of breathing and infant was suctioned less than the previous shift. Oxygen concentrations were still at ½ L. Will wean over next 12 hours.

Parent will be kept informed of the infants progress.

None needed unless the infant’s condition starts to deteriorate.