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Date: ___________Shift: ___________Nurse: ___________

NursingWorksheets.comPediatrics / NICU

PATIENT 1

Name:

Rm: ____

Age: ____

Allergies:

Code: ____

MD:

Dx:

VITALS

	0700	0900	1100	1300	1500	1700
HR
BP
RR
Temp
SpO2
Pain

WEIGHT-BASED DOSING

Weight (kg): ________ Date Verified: ________

Maint Fluids (4-2-1): ________ mL/hr

GROWTH PARAMETERS

Wt %ile: ____

Length: ____

Head Circ: ____

DEVELOPMENTAL

Age-Appropriate VS Ranges:

Dev. Considerations:

PARENT / GUARDIAN

Name:

Contact:

Present (Y/N):

FEEDING

Type (Breast/Formula/TPN):

Volume/Frequency:

Tolerance:

MEDICATIONS

Drug / Dose / Route	Time	Given	Notes

LABS

Na:

BUN:

Cr:

Glu:

WBC:

Hgb:

Plt:

Other:

IV ACCESS

Site/Gauge:

Fluid/Rate:

Date:

I&O

INTAKE

PO:

IV:

Blood:

Other:

Total:

OUTPUT

Urine:

Drain:

Emesis:

Other:

Total:

ASSESSMENT

PLAN / TASKS

NOTES

PATIENT 2

Name:

Rm: ____

Age: ____

Allergies:

Code: ____

MD:

Dx:

VITALS

	0700	0900	1100	1300	1500	1700
HR
BP
RR
Temp
SpO2
Pain

WEIGHT-BASED DOSING

Weight (kg): ________ Date Verified: ________

Maint Fluids (4-2-1): ________ mL/hr

GROWTH PARAMETERS

Wt %ile: ____

Length: ____

Head Circ: ____

DEVELOPMENTAL

Age-Appropriate VS Ranges:

Dev. Considerations:

PARENT / GUARDIAN

Name:

Contact:

Present (Y/N):

FEEDING

Type (Breast/Formula/TPN):

Volume/Frequency:

Tolerance:

MEDICATIONS

Drug / Dose / Route	Time	Given	Notes

LABS

Na:

BUN:

Cr:

Glu:

WBC:

Hgb:

Plt:

Other:

IV ACCESS

Site/Gauge:

Fluid/Rate:

Date:

I&O

INTAKE

PO:

IV:

Blood:

Other:

Total:

OUTPUT

Urine:

Drain:

Emesis:

Other:

Total:

ASSESSMENT

PLAN / TASKS

NOTES

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