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4 pages/β‰ˆ1100 words
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APA
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Health, Medicine, Nursing
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English (U.S.)
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Nursing Care Plan for Pediatric Care and SBAR Notes

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NURSING CARE PLAN ASSIGNMENT:
Two Care Plans and two SBAR notes will be completed during the semester. One for a Maternity Patient (choose: antepartum, intrapartum, postpartum) and one pediatric care plan (choose: NICU, well child, pediatric patient with complicating medical considerations). Students are responsible to collect data
When developing the nursing care plan, remember the following:
1. The focus is holistic and based on nursing clinical judgment using assessment data collected from a nursing framework. Continued assessment should be addressed in the care plan. Physical/psychological/spiritual/emotional needs may be included in holistic care.
2. The priority needs are identified and based on an identifiable nursing diagnosis.
3. There are patient-specific measurable nursing outcomes that are realistic.
4. Nursing interventions are focused on the etiologic or risk factors of the identified nursing diagnoses based on your progress notes.
5. Teaching should be included in most plans. (discharge teaching/family education, anticipatory guidance, interventions for care, assessment, emotional support...)

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Nursing Care Plan for Pediatric Care and SBAR Notes
Student Name
Institutional Affiliation
Course Code
Instructor
Date
Situation
Patient: J.S, a 6-month-old female infant admitted to the pediatric unit
Background
Primary Nursing Diagnosis: Deficient Fluid Volume related to acute gastroenteritis fluid losses.
Assessment: J.S. presents with vital sign abnormalities; physical exam findings and lab values show consistent fluid volume deficit, including tachycardia, tachypnea, fever, poor skin turgor, dry mucous membranes, and elevated BUN/Cr. She has a 3-day history of diarrhoea, vomiting, and poor intake resulting in 0.5kg weight loss, signs of clinical dehydration, and inadequate urine output.
Expected Outcome:
* J.S. will achieve consistently positive fluid balance with urine output of 2 ml/kg/hour sustained for 24 hours prior to discharge (Willacy, 2020).
* J.S.'s skin turgor, mucous membranes, and fontanel will return to normal limits
Nursing Recommendations:
* Administer intravenous fluids such as 0.9% normal saline with the rate titrated to replace measured ongoing losses and replete the deficit. Fluid boluses may be needed until urine output consistency improves (Replacement Fluid Therapy, 2017).

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