Integrated Primary Care (NURS 536)

Patient/ Family & Nursing Care Plan (10%)

Student Name

Student ID

Date

Primary Health Care Centre

Instructor Name

I.Patient Profile

Patient’s name (First & surname):

Healthcare Record Number (HRN):

Age:

Gender:

Presenting Chief complaint:

Accompanied by:

Source of data collection/gathering

Patient

Family or significant other Caregiver

EMS personnel Bystander

Use of translator

Medical Diagnosis:

II. Current problem/illness History (relating to the patient)

When did it start?

What are the symptoms?

Are others in the family ill with similar symptoms?

What has been done to treat symptoms

Primary Health care Practical (NURS 536) Patient/ Family & Nursing Care Plan (15%)

III. PAST MEDICAL HISTORY (referring to the patient)

A. Obstetrical history

Birth order: Terms of pregnancy

Full-term Pre-term

Mode of delivery:

Vaginal delivery Caesarian Section

Site of delivery

Home

Hospital

B. Past illness

Any data in past medical history that are significant and require further clarification. Consider previousacute illnesses including emergency department (ED) and urgent care, infectious diseases, hospitalizations, injuries, accidents, surgeries, and chronic illnesses. Consider how PMH relates to current presenting symptoms or problems.

C. Allergies

Medication—prescription, OTC Food/beverages

Latex Iodine

Environmental

D. Accident

E. Hospitalization

Year:

Medical diagnosis:

F. Immunization history

Complete Not complete

State why not complete:

G. Nutrition History

Timing and frequency of meals, including food choices if malnourished or obese; ethnic and cultural

Primary Health care Practical (NURS 536) Patient/ Family & Nursing Care Plan (15%)

considerations in food choices.

H. Social History

Exercise and activity, wellness behaviors, behavioral issues at home or at school. Use of media and Internet, friendships, bullying (either being bullied or bullies’ others), aggressive behaviors, violent behaviors, gender identity, and lesbian, gay, bisexual, transgendered, or queer (LGBTQ)+ status.

I.Development History

6 years and younger

Review results of prior developmental screenings, including the Denver Developmental Screening Test (DDST) orthe Ages and Stages Questionnaires, and socioemotional screenings.

Note achievement of developmental milestones at each interval visit. If delays are noted, question the status of intervention services (early intervention for children up to

6 years old; occupational therapy (OT), physical therapy (PT), speech, special education services, behavioral therapies for all children.

7 to 12 years old

Screenings based on presenting problem: Pediatric symptom checklist SCARED for anxiety.

Older than 12 years

Screenings based on presenting problem: Tobacco use or substance use HEEADSSS or SHADESS screen PHQ-2 and PHQ-9, if needed CRAFFT or Audit-C

J.Medication history

Prescription, OTC, homeopathic remedies, herbs, vitamins, minerals, other supplements.

Primary Health care Practical (NURS 536) Patient/ Family & Nursing Care Plan (15%)

K. Mental health

Assess mental health status for children and adolescents. Fears, anxiety, depression, and behavior problems may occur at any age.

L. Family history

Respiratory disease Cardiovascular disease; risk factors

Neurologic disease Endocrine disease Hepatic disease

Infectious disease Hematologic disease Immunosuppression Autoimmune disease Psychological disorders psychiatric or mental health

Others, Specify:

M. Socio-economic

1. Occupations of father and mother

2. Time spent with child by parents, activities together

3. Finances—adequacy

Primary Health care Practical (NURS 536) Patient/ Family & Nursing Care Plan (15%)

4. Persons in the home

5. House or apartment living arrangements

6. General relationship of family members or role characteristics of family

7. Community support systems—friends, church, agencies involved with family

8. Safety precautions

History of descriptive and non-descriptive medications:

Descriptive medications (Prescribed by physician/doctor):

Generic Name & / Classification

Trade Name

Dosage

Frequency

Route

Non-descriptive medications: Legal/ illegal, over the counter drugs (OTC):

Generic Name &

/Classification

Trade Name

Frequency

Route

Rationale

GENERAL ASSESSMENT

How would you describe your child's health right now?

Compared with other children, how healthy would you say your child is?

What does it mean for you to say that your child is “healthy”?

How do you describe good health in your family?

Do you have any questions or concerns about your child's health, growth, or development?

How important is it to you to have a regular health care provider?

BELIEF THAT HEALTH PRACTICES AFFECT HEALTH STATUS

What do you know about this current condition? What caused it? What can you do about it? What can you do to prevent it?

Has your child had a problem like this before?

How do you expect your child to respond when sick? To this sickness? What have you done for it in the past?

What do you do, or have you done that you believe makes a difference in how your child responds to illness?

What things can you do to help your child cope with being sick? What kinds of feelings do you have when confronted with sudden changes in plans or disruption of normal routine caused by illness in the family? How do you deal with those feelings?

How do you think those feelings affect the way you handle your child's health and illness?

DECISION-MAKING

What do you do when your child has health problems? What makes you decide to call your health care provider or take your child in for an examination?

Who makes decisions about health care in your family?

How do you make those decisions? Do you talk things over? Do you get advice from others?

Why do you think that you make decisions in that way?

What are the most important things that you consider when deciding about your child's health care?

What is most difficult for you when you must make decisions related to your child's health?

Health behaviors and use of resources

Do you have a regular health care provider for your child? When did you see that person last?

What health care resources are available to you? Is there a primary care provider you can get to conveniently? Clinics? Pharmacies?

What have you done to protect your child from injuries?

There has been much focus on healthy lifestyles, such as eating right and exercising. What does your family do regularly to stay healthy?

Does anyone in your family (adolescents, you) smoke, drink, or use drugs? How often? What kind? Are there other things that your family does that you think are bad for your children's health?

Who cares for your child when you are not at home and the child is not in school?

What helps you learn about health problems and how to take care of them— talking to others, reading, using the Internet, watching videos?

ENVIRONMENT

Do you use booster seats, seatbelts, or child restraints for your child when riding in a car?

Where does your child play? Do you believe it is safe?

Have you gone over personal safety with your child (e.g., “saying no”)?

Is your home childproof? If you have firearms, are they unloaded and locked? Is ammunition locked separately? Are pools fenced and gated?

How do you heat or cool your home? Is it comfortable?

Is there any danger of falls?

Is your child dressed warmly for cold weather?

Do you have a working smoke alarm?

What would you do if your child had a health emergency?

Do you have a car, or is there a friend, family member, or neighbor close by who could help you?

CHILDREN WITH SPECIAL NEEDS

What does it mean for you to say that your child is “healthy”?

How did you feel when your child's problem was diagnosed? What did you do? What coping strategies do you use as you care for your child?

How has managing a chronic illness changed your family’s functioning? How does your family function?

Who is providing specialty care to your child? Do you believe this is adequate? What other special needs do you believe your child has that require care?

How comfortable are you in providing home care?

How are your child's regular health needs met (i.e., those not directly related to the chronic illness, such as immunizations)?

What resources do you know about that can help you understand and manage your child's illness?

What special physical arrangements have you made to accommodate your child's illness? At home? In the car? At school or daycare?

V. Head-to-Toe Assessment (Review of Systems)

Describe only abnormal findings: Refer to PHC theory book)

General appearance

Skin

Hair

Head/ Neck/ Ears/ Nose

Mouth/ Throat/ Tongue

Lymph nodes

Hands/ Feet/ Nails

Primary Health care Practical (NURS 536) Patient/ Family & Nursing Care Plan (15%)

Chest/ Lungs

Heart/ Vascular

Abdomen

Neurologic

Musculoskeletal

Breast/ Genitalia / Anus

Diagnostic Examinations/Procedures:

(Include Blood type, Lactate, ABGS, ECG, CTCO2, Lab Tests, radiographic studies, etc…)

Test/Procedure

Reference Value (Normal

Results)

Patient Results

Nursing Considerations

Currently Prescribed Medications

Generic Name (Dosage, Route, Frequency)

Trade Name/ Classification

Adverse Reactions

Nursing Responsibilities

Treatments/Therapeutic Regimens/Doctor Orders rather than Medications

(e.g. oxygenation, IV therapy, immunization, etc.)

CHILD AND FAMILY PROBLEMS IDENTIFIED ACCORDING TO DOMAINS

Developmental

Functional Health

Pediatric/Adult disease

Priority the Problem Identified according to the Classification of System diagnoses (NANDA)

Developmental

Functional Health

Pediatric/Adult disease

ASSESSMENT

NURSING DIAGNOSIS

DESIRED OUTCOMES

NURSING INTERVENTION

RATIONALE

Child and family defining characteristics

Subjective/Objective)

Physician-prescribed:

Nurse prescribed (Discharge to home):