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College of Nursing, DMCH Format For Pediatric Nursing Clinical Presentation I

This document outlines the format for presenting a pediatric nursing clinical case, including sections for patient and student information, history of present illness, family history, physical assessment, growth and development assessment, disease condition assessment, nursing care plan, health teaching provided, and bibliography. The history section includes socioeconomic background, family history, birth history, personal history, medical history, surgical history, investigations, medications, and physical examination. [/SUMMARY]

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614 views4 pages

College of Nursing, DMCH Format For Pediatric Nursing Clinical Presentation I

This document outlines the format for presenting a pediatric nursing clinical case, including sections for patient and student information, history of present illness, family history, physical assessment, growth and development assessment, disease condition assessment, nursing care plan, health teaching provided, and bibliography. The history section includes socioeconomic background, family history, birth history, personal history, medical history, surgical history, investigations, medications, and physical examination. [/SUMMARY]

Uploaded by

isha
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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1

COLLEGE OF NURSING, DMCH

FORMAT FOR PEDIATRIC NURSING CLINICAL PRESENTATION

I. INTRODUCTION
a) Patient Information: Name, age, gender, educational status, address,
religion, diagnosis, date of admission, doctor in charge.
b) Student Information: Name, class, date of care started, date of care
ended ward/unit.
c) Brief introduction in a paragraph.
II. INTRODUCTION OF THE CHILD (Briefly in a paragraph)

III. HISTORY:

A) SOCIOECONOMIC BACKGROUND
i) Property, Income in addition to salary
ii) Family’s and social relationships
iii) Description of house and surroundings
iv) Family’s health attitude, belief and practice with regard to disease.
B) FAMILY HISTORY
i) Brief in 4-6 sentences.
ii) Family genogram
iii) Family’s details in a table.
Health status
S.No.

Age

Occupation
Gender
member

statusEducational
Name of

childRelation with

1.
2.

C) BIRTH HISTORY
a) Antenatal History
b) Intranatal History
c) Postnatal History
2

D) PERSONAL HISTORY

a) Diet History
b) Personal Hygiene
c) Sleep Pattern
d) Bowel and bladder pattern
e) Immunization status
f) Vital Signs

E) MEDICAL HISTORY
a) Past Medical History
b) Present Illness/Present Medical History

F) SURGICAL HISTORY
a) Past Surgical History
b) Present Surgical History

G) INVESTIGATIONS

H) MEDICATIONS

S.No. Form Name Dose Route Time of administration

Detailed Pharmacology of each drug:

a) Category
b) Action
c) Available forms
d) Indications
e) Contraindications
f) Dosage and routes
g) Side effects
h) Special precautions
i) Drug interactions, if any
j) Nursing considerations.

I) PHYSICAL EXAMINATION
a) General Appearance
b) Anthrometric Measurements
3

REGION FINDINGS INFERENCE


Head
Eyes
Ears
Nose
Mouth
Neck
Chest/Cardiovascular System
Respiratory System
Gastrointestinal system
Extremities
Back
Central Nervous System
Genitalia
Others

c) Summary

J) GROWTH AND DEVELOPMENT


a) Developmental History
b) Immunization
c) Developmental Aspects

ACCORDING TO LITERATURE IN CHILD


Physical/biological development
Gross motor
Fine motor
Cognitive development
Moral development
Language/Speech development
Play stimulation
Self Care
Psychosocial development
4

Psychosexual development
Spiritual development

Summary
K) Disease Condition:

a) detailed literature on disease


b) Comparison of clinical manifestations in the child with the literature

L) THEORY APPLICATION
M) NURSING PROCESS APPLICATION:

Assessment Nursing Expected Interventions Implementation Rationale Evaluation


Diagnosis Outcome Planned
Objective
Data:
Subjective
Data

N) HEALTH TEACHING TO CHILD AND FAMILY


O) EVALUATION
P) BIBLIOGRAPHY
Q) ARTICLES RELATED TO DISEASE CONDITION
Rupinder Deol,

Lecturer,CON,DMCH.

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