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Nursing Care Plan

Name of Patient: Kelly Kaye Lee Date: July 1, 2008 Ward: Pediatric
Age: 3 Sex: Female Weight: 15 kg. (33 lbs.) Shift: 3-11
Diagnosis: Acute Tonsillitis Date of Admission: July 1, 2008

Assessment Explanation of the Objectives Nursing Interventions Rationale Evaluation


Problem
C/C: Sore throat, 3 days Exposure to cold and STO:> Within 8 hours of Dx:> Assess v/s and record. > Provides baseline data for > Goal was fully met as
weather and too much nursing intervention, the Pt. comparison; elevation in evidenced by verbal report
S:> “Masakit lagi yung ingestion of sweets will report a decrease in rates may indicate that pain has decreased
lalamunan niya lalo na pag ↓ level of pain from to , > Assess pain worsening condition. form to , and
lumulunok”, as verbalized Entry of Pathogen and body temperature will characteristics including > Provides baseline data for temperature lowered from
by Pt.’s mother. ↓ lower from 38ºC to 37ºC. location and severity (using comparison and as 38ºC to 37ºC.
> Rated pain as using Disruption of cell the faces scale). reference for appropriate
the faces scale. membrane of tonsils Tx: > Place Pt. in a position diagnosis and management.
↓ of comfort, possibly semi- > Promotes comfort;
O:> Initial v/s taken as Release of chemical Fowler’s. Maximizes respiratory and
follows: mediators cardiac functions.
T= 38ºC ↓ > Offer more fluids and > Promotes adequate
RR= 40 breaths/min Activation of nociceptors LTO:> Within 3 days of semi-solid or moist foods, nutrition while lessening > Goal was fully met. Pt.
CR= 110 bpm ↓ nursing intervention, the Pt. as tolerated. difficulty in swallowing. has non-swollen and non-
> febrile Nerve impulses sent to will manifest the following > Offer ice chips, as > Decreases swelling of the tender lymph nodes on
> with swollen and CNS and are interpreted signs of improved tolerated. tonsils. submandibular area, has
tender lymph nodes on ↓ condition: > Assist Pt. in gargling > Relieves sore throat and pinkish and non-swollen
submandibular area Response of CNS sent to a. non-swollen and non- with saline solution. reduces swelling. tonsils, can easily swallow
> with bright red and systems tender lymph nodes on > Provide diversional >Helps Pt. to cope with fluids and semi-solid or
swollen tonsils ↓ submandibular area activities such as watching incompletely relieved pain. moist foods, and has
> appears irritable > Start of inflammatory b. pinkish and non-swollen TV, giving pop-up or maintained stable v/s.
> has difficulty in process tonsils coloring books, or playing
swallowing - vasodilation (redness) c. can easily swallow fluids with toys. > Promotes energy
A:> Acute pain r/t - increased cell and semi-solid or moist > Promote rest by conservation and lessen
inflammation of tonsils permeability (swelling) foods providing a quiet metabolic demands.
secondary to tonsillitis > Pain perception d. stable v/s environment and limiting
visiting hours. > Facilitates fluid-
> Regulate IVF to electrolyte replacement and
prescribed rate. balance; support circulating
blood volume to hasten
healing process.
> Treats underlying cause
> Administer antibiotics, of inflammation.
as ordered. > Decreases level of pain.
> Administer analgesics,
as ordered. > Facilitates participation
Edx:>Encourage the of both the Pt. and SOs in
presence of SOs at all the management of the
times, especially during condition.
procedures. > Maintains adequate
> Encourage SOs to hydration.
offer more fluids. > Supports adequate
> Encourage SOs to nutrition while lessening
provide small frequent difficulty in swallowing.
feedings of semi-solid or
moist foods. > Ensures continuity of
> Emphasize the need care; Prevents
to complete the 10-day complications, or
antibiotic regimen. recurrence of condition, or
resistance.
> Emphasize the need > Prevents progression of
to avoid exposure to present condition.
irritants and people with
infectious diseases.
> Explain possible > Prevents complications
complications of conditionand recurrence of
if inadequately treated. condition; Ensures
continuity of care.
> Emphasize preventive > Prevents complications
measures such as non- and recurrence of
exposure to irritants, condition; Ensures
adequate nutrition and continuity of care.
hydration, and vitamin C
supplementation.
Nursing Care Plan
Name of Patient: Lucky Chan Date: July 10, 2008 Ward: Pediatric
Age: 7 mos. Sex: Male Weight: 8 kg. (17.6 lbs.) Shift: 7-3
Diagnosis: Lactose Intolerance-Secondary Date of Admission: July 10, 2008

Assessment Explanation of the Objectives Nursing Interventions Rationale Evaluation


Problem
C/C: Passage of yellowish, Previous diarrhea episode STO: Within 8 hours of Dx:> Assess v/s and record. > Provides baseline data for > Goal was fully met. Pt.’s
watery stools, 8x in the last ↓ nursing intervention, the Pt. comparison; alteration in frequency in passage of
48 h Damage to intestinal villi will have a decreased rates may indicate watery stools decreased
↓ frequency in passage of worsening condition from 8x to 5x and Tº was
S:> “ Pururot, matubig, at Decreased lactase watery stools from 8x to 5x (dehydration). lowered from 37.8ºC to
madilaw yung tae niya production and will have a lowered Tº > Observe and record > Provides baseline data for 37ºC.
kahapon pa”, as verbalized ↓ from 37.8ºC to 37ºC. stool characteristics, comparison and as
by Pt.’s mother. Decreased ability to amount, and frequency of reference for appropriate
breakdown lactose elimination. diagnosis and management.
O:> Initial v/s taken as ↓ > Assess for signs of > Provides baseline data for
follows: Increased amounts of dehydration (pale comparison and as
T= 37.8ºC lactose in the small conjunctiva, poor skin reference for appropriate
RR= 42 breaths/min intestine LTO: Within 3 days of turgor, etc.) diagnosis and management. > Goal was fully met. Pt.
CR= 130 bpm ↓ nursing intervention, the Pt. > Monitor I and O. > A decrease in output may manifested improved
> passage of yellowish GIT microflora ferment will manifest improved indicate dehydration, hydration state as
watery stools, 8x in the last lactose hydration state as urinary, or absorption evidenced by non-sunken
48 h ↓ evidenced by non-sunken problems. eyes and good skin turgor-
> frequent flatus a. Gas (CO2) and acid eyes and good skin turgor- Tx: > Give ORS, as > Facilitates fluid- skin returned to normal
> sunken eyes (lactic) production skin returned to normal necessary. electrolyte replacement and position immediately;
> poor skin turgor-skin > gas=flatus position immediately ; balance. improved bowel
returned to normal position > acid=present in stool improved bowel > Give supplemental > Promotes adequate elimination pattern and
slowly b. Increased water retention elimination pattern and semi-solid foods, as nutrition. characteristics, as
> appears irritable; cries > =watery stool characteristics: tolerated and as necessary. evidenced by:
most of the time c. GIT transit time is a. passing out of light > Provide prompt > Maintains skin integrity; a. passing out of light
shortened yellowish semi-formed diaper change and gentle Prevents growth of MOs. yellowish semi-formed
A:> Diarrhea r/t > = frequency stools cleansing. stools
malabsorption of lactose b. decreased frequency in > Provide diversional > Helps keep the infant b. decreased frequency in
secondary to lactose passage of stools from 8x to activities such as playing from crying therefore passage of stools from 8x to
intolerance 3x with toys and socialization. decreases metabolic 3x
c. flatus significantly demands and keeps v/s c. significant decreased in
decreased stable. passing flatus
> Promote adequate rest > Decreases metabolic
periods. demands essential for
healing.
> Provide for temporary > Promotes adequate
change in diet or milk nutrition and healing while
formula, as ordered. preventing aggravation of
condition.
> Regulate IVF to > Facilitates fluid-
prescribed rate. electrolyte replacement and
balance; support circulating
blood volume to hasten
healing process.
Edx:> Encourage SOs esp. > Facilitates participation
the mother to be present at of both the Pt. and SOs in
all times esp. during the management of the
procedures. condition.
> Instruct SOs on ORS > Promotes fluid-
preparation, indications, electrolyte replacement and
and dosages. balance; Ensures continuity
of care.
> Encourage SOs to > Promotes adequate
provide lactose-free nutrition; Presents
supplemental feedings to variations in feeding.
infant as necessary.
> Explain to SOs the > Facilitates understanding
mechanism of the condition and cooperation of SOs.
(cause/s, management,
prognosis, etc.)
CASE 1:

A 3 year-old female child was brought to the hospital by her mother due to sore throat for 3 consecutive days. The mother verbalized that she is most worried about the pain felt by
her child especially when swallowing which causes her to eat and drink inadequately. The mother claimed that it started with a simple sore throat described to her as somewhat
itchy so she let the child gargle with saline solution but to no avail. During the second and third days, the child reported to her pain and difficulty in swallowing which made
feeding and drinking problematic, although the mother claimed that her child was still able to feed and drink even in small amounts. For the past 3 days, the child was reportedly
afebrile. When asked on what she thinks might have caused such condition, the mother reported that the child was exposed to the cold weather or “nahamugan” during their
vacation and that the child was very fond of eating sweets and chocolates. Assessment of the child revealed the following:

> throat pain rated as using the faces scale


> T= 38ºC (febrile)
> RR= 40 breaths/min (increased)
> CR= 110 bpm (increased)
> swollen and tender lymph nodes on submandibular area
> bright red and swollen tonsils
> appears irritable
> notable difficulty in swallowing

CASE 2:
A 7–month old female infant was brought to the hospital due to passage of yellowish watery stools for 8 times for the last 48 hours. The mother verbalized her worries since this is
the second diarrhea episode of the infant in the last 2 weeks; the first was due to bacterial infection. Because of this, the mother continued breastfeeding the infant by demand.
However, 2 days ago the infant started passing out yellowish watery stools again, accompanied by frequent flatulence. She also noted that her baby has been irritable and cries
most of the time since the condition started. The mother then increased the infant’s frequency in breastfeeding (since she was unsure in giving the infant ORS and feels that the
infant is not yet ready for semi-solid foods), but this action seemed to aggravate the infant’s condition so she immediately brought the infant to the hospital. Assessment of the
infant revealed the following:

> T= 37.8ºC (slightly increased)


> RR= 42 breaths/min
> CR= 130 bpm
> passage of yellowish watery stools, 8x in the last 48 h
> frequent flatus
> sunken eyes
> poor skin turgor-skin returned to normal position in 4 s
> appears irritable, cries most of the time