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Form from HIS OpenVista

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  1. 3/9/12
  2. 6/8/17
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June 8, 2017

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Creative Commons BY-NC 3.0
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NURSING ASSESSMENT (pedi)

HIS

  1. StudyEvent: HIS
    1. HIS
Child Nursing Assessment
see initial Admission Assessment
Neuro / Psychosocial
Normal Baseline: Alert, appropriate verbalization, response appropriate for age, pupils equal and reactive, sensation intact.
GLASGOW COMA SCALE ADULT
EYES OPEN
BEST VERBAL RESPONSE
BEST MOTOR RESPONSE
Pupils
mm
mm
GLASGOW COMA SCALE CHILD
EYES OPEN
BEST VERBAL RESPONSE
BEST MOTOR RESPONSE
ORIENTATION
Cardiovascular system
Normal Baseline: Regular rate and rhythm, no edema, capillary refill less than 2 seconds, pink nailbeds, warm extemities, peripheral pulses strong and regular.
TEDS ON
SCDS ON
Cardiac Pacemaker
Eyes Ear Nose & Throat
Normal Baseline EYES: Without drainage, sclera white.
Normal Baseline EARS: No complaint of pain.
Normal Baseline NOSE: No drainage or congestion.
Normal Baseline THROAT: No complaint of pain.
Eyes
mm
mm
Drainage
EARS
C/O Pain
Hard of Hearing
Hearing Loss
Deafness
Hearing Aids
Patent
Dizziness
Tinnitus, Ear noises, Ear ringing
Drainage
Nose
Nares patent
Nares Drainage
Pharynx, Throat
Sore throat, Pain in throat, Pharyngeal pain
Mouth Sores
Respiratory
Normal Baseline Respiratory: Unlabored respirations, BBS clear, chest rise symmetrical, pink mucous membranes.
CHEST EXPANSION
INCENTIVE SPIROMETRY DONE
Pulse Oximeter present with alarms set
Cardio-Respiratory Monitor present with alarms set
CHEST TUBE PRESENT
CHEST TUBE LOCATION
Air Leak
Gastrointestinal
Normal Baseline GI: Abdomen soft, nondistended, bowel sounds normoactive in all quadrants.
FLATUS
Incontinence
NG placement checked
Tube feeding (TF), Enteral tube feeding
RECTAL BAG PRESENT
Genitourinary system, Urogenital system
Normal Baseline Genitourinary: Voids without pain or hesitation, no suprapubic distention.
Sex
INCONTINENT
VOIDS SUFFICIENT QUANITY
IS PATIENT RECEIVING DIALYSIS
ODOR PRESENT
catheter present
SEXUALLY ACTIVE
CURRENTLY ON MENSES
Discharge (Dx)
Musculoskeletal System, Musculo-skeletal system
Normal Baseline Musculoskeletal: Full ROM, no muscle weakness, bones intact, gait steady or age appropriate.
GENERALIZED WEAKNESS
LIMITED ROM
LIMITED MOBILITY
Hemiplegia Side
GRIPS EQUAL
UNSTEADY GAIT
Integument
Normal Baseline Skin: Warm, pink, dry, elastic, intact, moist mucous membranes.
MOIST
Surgical incision
Dressing Changed
Wound
Undermining
Tunneling
Odor: Before Cleaning
Odor: After Cleaning
Nutrition
NPO
Tube feeding (TF)
intravenous therapy
IV HEPLOCKED
IV DISCONTINUED
CATHETER INTACT
PLACED ON IMED
patient safety
SIDE RAILS UP
IN LOW POSTION
CALL BELL WITHIN REACH
ALLERGY BAND ON
NAME BAND ON
BLOOD BAND ON
FALL BAND ON
Pediatric Fall Risk Assessment
LEVEL OF CONSCIOUS
Seizures/Previous history of falls
MEDICATION/EQUIPMENT
LENGTH OF STAY
ELIMINATION
GET UP AND GO TEST: "RISING FROM A CHAIR"
INTERVENTIONS
Assist with Ambulation
Reorient Q2H or Less
Gait Belt
ID Patient at Risk
Restraints (see policy)
Multi-personnel Transfer
Close Observation
Non-slip Footwear
Bed in lowest position
Lock wheels of vehicles of conveyance during transfer
Upper siderails raised
Call light in reach
Offer toileting at least every 2 hours
Offer fluid/nutrition every 2 hours
Place frequently used objects within reach
Provide adequate lighting
Provide sensory impairment/orientation devices (clocks,etc)
Provide adequate rest periods
Use age appropriate distractions for confusion/disorientation
Remove harmful hazards
Provide appropriate and least restrictive patient supervision/surveillance
Communicate information about fall risk to caregivers
Encourage family/support system to participate in care
Teach/educate family/support system Fall Prevention information
Implement Fall Prevention Protocol for Hendrich II Score>5
IMPAIRED MOBILITY RISK
Implement Universal Fall Prevention Intervention
Monitor transfers to/from bed/chair(etc.)
Use appropriate assistance for transfers to/from bed/chair
Use chairs with armrests and of proper height for transfers
Implement progressive ambulation(unless contraindicated by condition/orders)
Encourage/Provide self-care assistance
Remain in attendance during toileting/ADL's
Provide assistive devices for ambulation (canes/walkers/etc.)
Gait Belt during transport/ambulation
Teach patient/family to call for help and WAIT for help before
attempting any transfer/ambulation
ALTERED ELIMINATION
Implement Universal Fall Prevention Interventions
Remain in attendance during toileting/ADL's
Assist with post-elimination hygiene
Remove non-essential clothing
Instruct patient on importance of toileting when offered by staff
Monitor for 'patient's normal' bladder/bowel habits
Monitor for causes of incontinence (diuretics,cathartics,etc.)
Monitor skin integrity
HIGH RISK FALL MEDICATIONS (ANTIEPILEPTICS & BENZODIAZEPINES)
Implement Universal Fall Prevention Interventions
Monitor drug dosages
Evaluate sensory functions
Monitor/Assess for drug overdose
Monitor response to exercise
Educate patient/support system about drug classification, side effects,
precautions, toxic symptoms of overdose.
Hendrich II Fall Risk Assessment
ONN Unit specific
Post Surgical
ADOLESCENT INTERACTION
Prepared for treatment/procedure as soon as possible.
Provided detailed information about events/procedures/treatments.
Allowed contact with peer group.
GERIATRIC INTERVENTION (65+)
Involved in decision process regarding pain control/medication/care decisions
Encouraged family/S.O.to visit
Independence promoted.