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Write an APA formatted Nursing Care Plan for a pediatric patient. The setting/patient is a 9 year old female at a summer camp infirmary clinic, diagnosed with acute otitis media (“swimmer’s ear”) Specific information such as vital signs and lab values, or storyline can be made up. The paper should be 6-7 pages, not including reference page etc. I will also include some example care plans for reference. Rubric criteria below: Introduction: 1 paragraph The introduction should tell “the story“ of the patients’ admission, day of care (Day 1, 2, 3 … since admission), the primary diagnosis to identify what has occurred since admission, and what the priority for care is now. Follow all HIPAA guidelines. Medical Diagnosis & Significant Co-Morbid Diagnosis justifying your selections Pathophysiology of 1 selected (priority) Medical Dx · Organs affected · Pathophysiology of Dx The pathophysiology section should present a priority issue at the time of care of the patient. This section should be concise (1-2 paragraphs, and an explanation of how the pathophysiology specifically relates to the patient. The use of citations to support patho data is required. Assessment (3-5 paragraphs) · VS, HTT (overview) and specifically addressing any deviations from normal or related to diagnosis/disease process (you may use tables for VS values in Appendix or Appendices if needed) · Neuman Variables and Stressors-Identify all areas Assessment using Neuman System Model (Variables: Physiologic, Psychological, Spiritual, Developmental, Sociocultural) and the affect of stressors on variables. (Stressors: Intra-personal, Inter-personal, Extra- personal). Describe Erickson’s or Piaget Developmental Stage with citations for support. Lab Values and Diagnostics: · Labs & Diagnostics (e.g., radiology, nuclear medicine) directly r/t pathophysiology and assessment findings · Discuss significant variations and values/results that may be pertinent to the selected patient diagnosis and current treatment · Discuss trends in selected values/results if appropriate to evaluate progress of care (Requirement: Include a table in the appendix for lab and diagnostic values; the discussion of the priority values/results is in the body of the paper). Medications and Collaborative Interventions: Identify 3 priority medications and/or any medications you have administered to the patient, which includes: Classification, reason for medication, expected outcomes of the medication, and any nursing implications. Evaluate the effectiveness of the medication. Nursing considerations. (Requirement: Include a table in the appendix for medication list if necessary for complete list; the discussion of the medications is in the body of the paper) · Identify 2 collaborative Interventions or treatments (e.g., RT, PT, Dietician, Wound Care, OT, Dialysis, Case Management, etc.). The MD is a wonderful and important teammate. In this section we are not looking to just at MD but who else and what else are collaborative partners in this patients care? Nursing Diagnosis and Individualized Plan of Care This should include the (NANDA) Nursing Diagnosis, Goal/Outcome, Intervention, and Evaluation (see below) Based on the assessed Neuman variables and stressors, and Patho. (2) Two diagnoses must be physiological, and (1) one other priority non-physiological diagnosis of your choice. (3 concise paragraphs). These Nursing Diagnosis must be NANDA approved. Goals/Outcome (SMART): · Short term (shift-long) · Measurable by 2 criteria with target dates.
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