Case Scenario #4

Pediatric Acute Care

INSTRUCTIONS: For this case scenario, you will develop a Nursing Care Plan using SNL, the Standardized
Nursing Languages of NANDA, NOC and NIC (NNN). You will be completing the blank nursing care plan
that you have printed.
Patient is a 10-month old girl admitted to your unit from the PACU following Laparotomy Nissen
procedure and gastrostomy tube placement. She is sleeping comfortably. VS are WNL. IV of D5/.45
w/10 meq KCL is infusing at 20 cc/hr. Patient is NPO. Gastrostomy tube is ordered to low continuous
suction. Meds include Morphine 0.5 mg q 2-3 hrs.

Functional Health Patterns

Nursing assessment data is organized in Functional Health Patterns. Functional Health Patterns can help direct
the choice of Nursing Diagnoses. The eleven functional health patterns are Health Perception-Health Management;
Cognitive-Perceptual; Nutritional-Metabolic; Elimination; Activity-Exercise; Sleep/Rest; Self-Perception/Self-
Concept; Role/Relationship; Sexuality/Reproductive; Coping/Stress/Tolerance; and Value/Belief.

Ø Health Perception/Management:
Former 32 week Premie with history of multiple occurrences of vomiting, respiratory
distress and pneumonia.
Recently diagnosed with GERD (Gastro-esophageal reflux disease).
Home meds include Cisapride, Zantac, Atrovent and Albuterol.
Parents expect that she will be in the hospital for approximately 5 days and will go home on her
prior feedings. They are unsure of the purpose and care of GT.
Ø Role/Relationship:
Parents accompany child to the unit.
Patient lives with parents and two older siblings, ages 3 and 5.
Both parents work, and patient goes to day care 5 days a week. They will be unable to stay with
the patient during her hospitalization.
Ø Nutrition/Metabolic:
Takes 4-5 oz. of Similac with Fe 5x/day plus 2-3 jars of strained food.
She vomits moderate amount soon after eating 2-3 x/day.
Current weight = 5 kg. She has fallen off the growth curve.
Ø Activity/Exercise:
Patient has become less active especially during occurrences of pneumonia.
Ø Cognitive/Perceptual:
Developmental milestones are at approximately a 6-month-old level.
Sits independently but does not crawl or pull self to standing.
Has no problem with hearing or vision.
Has not been connected with Early Intervention Services.

Nutritional/Metabolic
is the most affected functional health pattern for this patient at this period of time.
.

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 Nursing Diagnosis
Appropriate nursing diagnoses (NANDA) for this patient would include:
Altered nutrition: Less than body requirements
Defining Characteristics:
Reported inadequate food intake
Body weight less than normal
Related factors (Etiology):
Inability to digest nutrients.
Recurrent pneumonia
Pain
Defining Characteristics:
FLACC score >5 (Verbal/coded report)
Related factors (Etiology):
Operative procedure
Knowledge deficit
Defining Characteristics:
Verbalizes lack of information about gastrostomy tube.
Related factors (Etiology):
Unavailability of parents to learn care.

While all these nursing diagnoses are appropriate, for purposes of this exercise let’s use:

Altered nutrition: Less than body requirements.

On the nursing care plan form write in the nursing diagnosis, identifying the defining
characteristics and related factors.

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 Nursing Outcomes (NOCs)

• The next step is to select nursing outcomes that can best affect this nursing diagnosis.

• Listed below are two appropriate nursing outcomes for this patient.

Nutritional Status: Food & Fluid Intake

Indicators:
Oral food intake
Tube feeding intake
Oral fluid intake
IV fluid intake

Nutritional Status: Energy

Indicators:
Growth
Tissue healing
Infection resistance
Endurance

Select one of the above listed nursing outcomes for this care plan exercise, go to the
nursing care plan form and check the indicators that you think will best measure your
patient’s progress towards the outcome that you have chosen. You will need to rate your
patient’s current status for each indicator.

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 Nursing Interventions – NIC
Now that you have chosen your outcome for this patient, you will select the interventions
that will best meet this outcome.
• If you have chosen the NOC, Nutritional Status: Food & Fluid Intake, continue below.
• If you have chosen the NOC, Nutritional Status: Energy, continue to that section.

NOC-Nutritional Status: Food and Fluid Intake

The following two Nursing Interventions are appropriate for this patient. Review the activities
listed below each NIC and select 5 that apply. Write these five on the nursing care plan in the
activity column.
NIC: Fluid Management–Activities
• Weigh daily and monitor
trends
• Monitor hydration status
(e.g., moist mucous
membranes, adequacy of
pulses, and orthostatic
blood pressure), as
appropriate
• Assess location and extent
of edema, if present
• Monitor patient’s weight
change before and after
dialysis, if appropriate
• Administer IV therapy, as
prescribed
• Administer prescribed
diuretics, as appropriate
• Instruct patient on nothing
by mouth (NPO) status, as
appropriate
• Encourage significant other
to assist patient with
feedings, as appropriate
• Monitor patient’s response
to prescribed electrolyte
therapy
3
(,p.348)
• Count or weigh diapers as
appropriate
• Monitor for indications of fluid
overload/retention (e.g.,
crackles, elevate CVP or
pulmonary capillary wedge
pressure, edema, neck vein
distention, and ascites), as
appropriate
• Monitor vital signs, as
appropriate
• Monitor hemodynamic status,
including CVP, MAP, PAP, and
PCWP, if available
• Monitor nutrition status
• Administer IV fluids at room
temperature
• Administer prescribed
nasogastric replacement based
on output, as appropriate
• Offer snacks (e.g., frequent
drinks and fresh fruits/fruit
juice), as appropriate
• Consult physician, if signs and
symptoms of fluid volume excess
persist or worsen
• Administer blood products (e.g.,
platelets and fresh frozen
plasma), as appropriate
• Maintain accurate intake and output
record
• Monitor laboratory results relevant to
fluid retention (e.g., increased specific
gravity, increased BUN, decreased
hematocrit, and increased urine
osmolality levels
• Insert urinary catheter, if appropriate
• Monitor food/fluid ingested and
calculate daily caloric intake, as
appropriate
• Give fluids, as appropriate
• Distribute the fluid intake over 24 hr.,
as appropriate
• Promote oral intake (e.g., provide a
drinking straw, offer fluids between
meals, and change ice water routinely),
as appropriate
• Restrict free water intake in the
presence of dilutional hyponatremia
with serum Na level below 130 mEq per
liter
• Arrange availability of blood products
for transfusion, if necessary
• Prepare for administration of blood
products (e.g., check blood with patient
identification and prepare infusion
setup), as appropriate

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NIC: Enteral Tube Feeding-Activities (p.304)
• Insert a nasogastric,
nasoduodenal, or nasojejunal
tube, according to agency
protocol
• Request that tube
placement be checked by x-
ray examination when
placement is questionable
• Consult with other health
care team members in
selecting the type and
strength of enteral feeding
• Hold and talk to infant
during feeding to simulate
usual feeding activities
• Irrigate the tube every 4 to
6 hr. during continuous
feedings and after every
intermittent feeding
• Slow tube feeding rate
and/or decrease strength to
control diarrhea
• Hold tube feedings if
residual is greater than 150
cc or more than 110% to
120% of the hourly rate in
adults
• Change feeding and infusion
tubing regularly, according
to agency protocol
• Discard enternal feeding
containers and
administration sets every 24
hours
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3
• Applying anchoring
substance to skin, and
secure feeding tube with
tape
• Monitor for presence of
bowel sounds every 4 to 8
hr., as appropriate
• Elevate head of the bed
during feedings
• Discontinue feedings 30
to 60 min. before putting
in a head-down position
• Use clean technique in
administering tube
feedings
• Monitor for sensation of
fullness, nausea, and
vomiting
• Keep cuff of endotracheal
or tracheostomy tube
inflated during feeding, as
appropriate
• Wash skin around skin
level device daily with mild
soap and dry thoroughly
• Refill feeding bag every 4
hr., as appropriate
• Monitor for proper placement of
the tube by inspecting oral cavity,
checking for gastric residual, or
listening while air is injected and
withdrawn, according to agency
protocol
• Monitor fluid and electrolyte status
• Offer pacifier to infant during
feeding, as appropriate
• Add blue food coloring to tube
feedings to monitor for aspiration
or fistula
• Check gravity drip rate or pump
rate every hour
• Check residual every 4 to 6 hr.
during continuous feedings and
before each intermittent feeding
• Keep open containers of enternal
feeding refrigerated
• Check water level in skin level
device balloon, according to
equipment protocol
• Prepare patient for home tube
feedings, as appropriate
NOC-Nutritional Status: Energy

NIC: Weight Gain Assistance-Activities (,p.703) 3

• Refer for diagnostic • Weigh patient at specified
workup to determine intervals, as appropriate
cause of being
underweight, as
appropriate
• Monitor for nausea and • Determine cause of nausea
vomiting and/or vomiting, and treat
appropriately
• Monitor daily calories • Monitor serum albumin,
consumed lymphocyte, and electrolyte
levels
• Instruct on how to • Provide a variety of high-
increase calorie intake calorie nutritious foods from
which to select
• Provide oral care before • Provide rest periods, as
meals, as needed needed
• Assist with eating or • Provide foods appropriate for
feed patient, as patient: general diet,
appropriate mechanical soft, blenderized
or commercial formula via
nasogastric or gastrostomy
tube, or total parental
nutrition, as ordered by
physician
• Serve food in a pleasant, • Discuss with patient and
attractive manner family socioeconomic factors
contributing to inadequate
nutrition
• Refer to community • Teach patient and family
agencies that can assist meal planning, as appropriate
in acquiring food, as
appropriate
• Reward patient for • Chart weight gain progress
weight gain and post in a strategic
location
• Discuss possible causes of low body
weight
• Administer medications to reduce
nausea and pain before eating, as
appropriate
• Encourage increased calorie intake
• Consider patient’s food
preferences, as governed by
personal choices and cultural and
religious preferences
• Ensure that patient is in a sitting
position before eating or feeding
• Create a pleasant, relaxing
environment at mealtime
• Discuss with patient and family
perceptions or factors interfering
with ability or desire to eat
• Teach patient and family how to buy
low-cot, nutritious foods, as
appropriate
• Encourage attendance at support
groups, as appropriate

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NIC: Nutritional Monitoring-Activities (,p.477) 3

• Weigh patient at • Monitor trends in weight loss • Monitor type and amount of usual
specified intervals and gain exercise
• Monitor patient’s • Monitor parent/child • Monitor environment where eating
emotional response when interactions during feeding, occurs
placed in situations that as appropriate
involve food and eating
• Schedule treatments and • Monitor for dry, flaky skin • Monitor skin turgor, as appropriate
procedures at times with depigmentation
other than feeding times
• Monitor for dry, thin • Monitor gums for swelling, • Monitor for nausea and vomiting
hair that is easy to pluck sponginess, receding, and
increased bleeding
• Monitor skinfold • Monitor albumin, total • Monitor lymphocyte and electrolyte
measurements;triceps protein, hemaglobin, and levels
skinfold, midarm muscle hematocrit levels
circumference, and
midarm circumference
• Monitor food • Monitor growth and • Monitor energy level, malaise,
preferences and choices development fatigue, and weakness
• Monitor for pale, • Monitor caloric and nutrient • Monitor for spoon-shaped, brittle,
reddened, and dry intake ridged nails
conjunctival tissue
• Monitor for redness, • Note any sores, edema, • Note if tongue is scarlet, magenta,
swelling, and cracking of hyperemic and hypertrophic or raw
mouth/lips papillai of the tongue and oral
cavity
• Note significant changes • Initiate a dietary consult, as • Determine whether the patient
in nutritional status and appropriate needs a special diet
initiate treatments, as
appropriate
• Provide optimal • Provide nutritional food and
environmental conditions fluid, as appropriate
at mealtime

Congratulations!
You have successfully completed your first nursing care plan using the standard nursing language
vocabularies of NANDA, NOC, and NIC.

1. If you wish to received CE for this educational activity, please complete the evaluation form and
return along with $10 to:
Carol Williams, MS, RN, C
Educational Services for Nursing
University of Michigan Health System
300 North Ingalls , 6B12
Ann Arbor, Michigan 48109-0436

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2. If you are working with a coordinator please give your quiz, evaluation and completed nursing care plan to your coordinator.

Pediatric Acute Care

NURSING DIAGNOSIS : Patient Name
Defining Characteristics (Signs & Symptoms)
❏ ❏ ❏
❏ ❏ ❏
❏ ❏ ❏

Related Factors (Etiology)

❏ ❏
❏ ❏
❏ ❏

NOCs (Outcomes)
Measurement Scale Score:
1 = Not adequate
2 = Slightly adequate
Nutritional 3 = Moderately adequate
4 = Substantially adequate
Status:
5 = Totally adequate
Food & ❏ Oral food intake
Liquid ❏ Tube feeding intake
Intake ❏ Oral fluid intake
❏ IV fluid intake
DATE/TIME
INITIALS

Measurement Scale Score:

1 = Extremely compromised
2 = Substantially compromised
3 = Moderately compromised
Nutritional 4 = Substantially compromised
5 = Not compromised
Status:
❑ Growth
Energy ❑ Tissue healing
❏ Infection resistance
❑ Endurance
DATE/TIME
INITIALS

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 NICs (interventions)ACTIVITIES: MODIFICATIONS:
❑
❑
Fluid
❑
Management ❑
❑
DATE/TIME
ACTIVITIES: MODIFICATIONS:
❑:
❏
Enteral Tube
❏
Feeding ❏
❑
DATE/TIME
ACTIVITIES: MODIFICATIONS:
❏
❏
Weight Gain
❏
Assistance ❏
❏
DATE/TIME
ACTIVITIES: MODIFICATIONS:
❏
❏
Nutritional ❏
Monitoring ❏
❏
DATE/TIME
OTHER INTERVENTIONS: SIGNATURE BOXES:
• •
• •

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