CHILD HEALTH NURSING

OMAN COLLEGE OF HEALTH SCIENCES-AL DHAHIRA BRANCH
CHILD HEALTH NURSING
Comprehensive Case Study
St.Name: St.No: Week: Date: PW:
INTRODUCTION:
I. GENERAL INFORMATION
State your reasons for selecting this particular client/child and write the medical diagnosis
(definition).
Critical thinking questions:
– How did you establish trust with the child and family?
– What was the best approach worked in this situation?
– Any relevant past history /family history / birth history which is related to the child’s present
condition?
a. BASELINE DATA:
Patient’s Name: Patient’s ID No:
Age: DOB: DOA:
Medical Diagnosis:
b. BIRTH HISTORY:
Type of
Delivery:
 Normal  LSCS  Forceps  Vacuum
Birth:  Term  Preterm  IUGR
Birth weight: Birth length: Head Circumference:
Apgar Score: At birth (1 min): At 5 min:
Congenital
anomalies:
c. CHIEF COMPLAINTS:
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d. PRESENT MEDICAL/SURGICAL HISTORY:
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e. PAST MEDICAL/SURGICAL HISTORY (Any relevant past history/ family/ birth
history related to the child’s present condition)
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II. PATHOPHYSIOLOGY:
a. From Reference
b. In the Child
III. PHYSICAL EXAMINATION
a. Child health indicators & Plotting Growth Chart (Pls attach)
b. Physical Examination Summary
Vital Signs:
T RR HR BP Apical
Pulse
Wt Expecte
d
WT
Ht HC
1. Head:
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2. Chest:
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3. Abdomen:
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4. Back:
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5. Extremities:
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6. Neurological examination:
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c. Physical Assessment Tool (Pls attach)
IV. DEVELOPMENTAL MILESTONE ASSESSMENT
Describe the stages the child is in, how he/she performs compared to children of same age.
Supporting examples and reasons
MOTOR DEVELOPMENT:
Gross Motor Fine Motor
a. PSYCHOSOCIAL DEVELOPMENT:
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b. COGNITIVE DEVELOPMENT:
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c. MORAL DEVELOPMENT:
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d. LANGUAGE DEVELOPMENT:
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Critical thinking questions:
 Critical thinking questions:
• How did growth and development assessment help you in providing care to the child?
• How did growth and development assessment help you in preparing the child for various
procedures?
e. PLAY ASSESSMENT:
 Type of play, interests and toys.
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V. HEALTH PROTECTION AND PROMOTION
Immunization / Vaccine Date administered
Sleeping Pattern:
Nutrition Status:
Elimination Pattern:
Injury Prevention Measures:
a.
b.
c.
d.
VI. DIAGNOSTIC TEST PROCEDURES: Types and Indications date, results and the
interpretation of results.
INVESTIGATIONS:
Investigation/Date Purpose of
Performing the Test
Findings Interpretation of the
Findings
OTHER PROCEDURES:
VII. TREATMENT COURSE
a. TREATMENT TYPE & ROLE OF FAMILY IN THE COURSE OF
TREATMENT AND PROGRESS
b. MEDICATION PRESCRIBED (Use additional papers if needed):
Drug Name
Dose/Frequency/
Route:
Why was it prescribed to
the patient and will it
help?
Nursing Responsibilities
before/during &after
administration
1 Before:
During:
After:
2 Before:
During:
After:
3 Before:
During:
After:
4 Before:
During:
After:
5 Before:
During:
After:
c. CHILD’S DIET , MODIFICATIONS AND RATIONALE:
VIII. HEALTH EDUCATION DESCRIPTION:
HEALTH EDUCATION:
(attach evidence of the planned Health Education)
1.
2.
3.
4.
IX. DISCHARGE PLAN:
X. NURSING CARE PLAN
a. HEALTH NEEDS IDENTIFIED:
Health Need Supporting Data
1.
2.
3.
4.
5.
Critical thinking question:
• What was your priority nursing diagnosis? Reasons for making this particular diagnosis as
priority?
# Assessment / Nursing Diagnosis Goals/Outcome Implemented NSG
Interventions
Rational Evaluation
1
2
3
XI. PERSONAL REFLECTION (Answer in paragraph form)
Describe how the case study was valuable to you.
What was new to you? What surprised you?
What do you expect to remember the most?
How can you apply what you have learned to your personal and professional life, both now and in the future?
XII. EVIDENCE BASED SUMMARY using PICO:
Population
Intervention
Control
Outcome
Citation Purpose Sample Measurement Design Result/ Findings
Summary:
REFERENCE (APA FORMAT):

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