Provide appropriate level

of supervision
Rationale: monitors childs
wellbeing and allows for
prompt intervention

Initiate safety precautions

such as bed in low position,
childproof containers, and
appropriate use of side rails
Rationale: preventing injury
& complications is a prime
responsibility of caregivers

Assessment: Pt.
noted to not want to
put pressure on rt.
leg r/t procedure on
his knee. Pt.
whimpers when put
in a position when
knee is not supported

Monitor HR & BP using

correctly sized cuff and
respiratory rate noting ageappropriate normal and
variations

Encourage sleep
and rest periods
Rationale: Helps
reduce fatigue and
enhances coping
ability

Rationale: changes in
autonomic responses may
indicate increased pain
before the child verbalizes

Handle toddler gently

Observe for guarding, rigidity,
crying and restlessness

Rationale: skin and

tissues are fragile and are
at risk for damage

Assessment: Pt. continuously

wants interaction w/ parent at
the bedside and this may
entail getting out of the bed.
Pt. has demonstrated agitation
w/ IV line but no signs of
infiltration were present. Bed
in low position, call bell w/in
reach and hourly rounds made

Rationale: nonverbal
expression, body
movements, and behavioral
state may signal pain or
changes in pain severity

Septic Arthritis
Outcome
met. No
injuries
occurred

Pt. Wt=
13.7 kg

ND (3): Anxiety r/t

hospitalization AEB
restlessness, sleep
disturbances, and crying

Outcome partially
met. During the 11
am rounding FLACC
scale was a 2 but
went back down for
the remainder of shift

OUTCOME: the child will

appear relaxed and
demonstrate relief from
somatic manifestations
of anxiety for at least
half of the 8 hour shift.

-Pepcid IV 0.5 mg/kg= 6.85

mg, 13.2 ml/hr
- Toradol IV (PRN) 0.5 mg/kg =
6.9 mg (over 1-5 min

Schedule ample time for play

and age appropriate diversions

-Vancomycin 250 mg in 50 ML
syringe @ 25mL/hr

Assessment: Pt. woke up

pleasant and agreeable. About
1 hr before pain medicine was
due, pt. became increasingly
agitated while trying to take
vital signs. Mother reports
increased anxiousness related
to lack of sleep .

Rationale: promotes normalcy

and helps divert attention from
the situation

Maintain home
routines whenever
possible. Encourage
the parents to bring
toys from home.

Help family support

child emotionally by
being available and
active listening.

Rationale: enhances
a sense of security
when child is
hospitalized

Rationale: Conveys
acceptance of child
and confidence in
ability to cope with
situation

Outcome was met

as the child only
appeared anxious
for approximately
one hour