Pediatric Nursing Care Plan

Pediatric Nursing Care Plan

Enerolisa Paredes

NUR 405: Therapeutic Intervention IV

Instructor: Professor Ramirez

April 22, 2017

Lehman College Department of Nursing

NUR 405

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Pediatric Nursing Care Plan

ASSESSMENT GUIDE AND NURSING CARE PLAN

STUDENT NAME: Enerolisa Paredes DATE: 04/22/2017

FACULTY NAME: Professor Ramirez

DATA COLLECTION

Health History

SOURCE AND RELIABILITY OF DATA:

Health history data was collected from JMs mother who is fluent in English as well as Spanish.

History collected from the mother is reliable. She appeared calm without any distraction and

answered the questions posed.

DATE OF EXAM: 04/08/2017 CLIENTS INITIALS: JM AGE: 10 years

SEX: Female DOB: 05/06/2007

RELIGION: Christian ETHNICITY: Hispanic

LANGUAGE (S) SPOKEN: Spanish, English

EDUCATION: 4th grade

REASONS FOR SEEKING CARE (CHIEF COMPLAINT):

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JM presented to the Urgent Care with sore throat, fever, runny nose and nasal congestion for the

past 3 days.

DIAGNOSIS:

1. Pharyngitis

PAST MEDICAL HISTORY & DIAGNOSES:

Asthma (1 year old to present)

Eczema (2 years old to present)

SURGICAL INTERVENTIONS/HISTORY:

No known history

GENERAL ESTIMATE OF HEALTH PRIOR TO THIS ADMISSION

As per mother said, besides having asthma, which is in good control. Patient is in good health

IMMUNIZATION HISTORY

Up-to -date

DEVELOPMENTAL LEVEL (Psychosocial/ Cognitive)

According to Piagets period of Cognitive Development JM is at Period 3 Concrete Operational

Stage (7-11 years). Piaget considered the concrete stage a major turning point in the child's

cognitive development, because it marks the beginning of logical or operational thought. This

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means the child can work things out internally in their head (rather than physically try things out

in the real world).

According to Ericksons stages of psychosocial development JM is at I Industry vs. Inferiority

Competence

During this stage, often called the Latency, we are capable of learning, creating and

accomplishing numerous new skills and knowledge, thus developing a sense of industry. This is

also a very social stage of development and if we experience unresolved feelings of inadequacy

and inferiority among our peers, we can have serious problems in terms of competence and self-

esteem. As the world expands a bit, our most significant relationship is with the school and

neighborhood. Parents are no longer the complete authorities they once were, although they are

still important.

ALLERGIES: No known Drug allergies

ACCIDENTS &/OR INJURIES: No history of accidents or injuries

FAMILY HEALTH HISTORY

Mother has obesity

Father is healthy

Paternal Grandfather has Diabetes, Hypertension and Colon Cancer

Paternal Grandmother has HTN

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Pediatric Nursing Care Plan

Maternal Grandfather has Diabetes and Hypertension

Maternal Grandmother has Anemia

FAMILY (Attach Patients - 3 Generation Genogram)

GRANDFATHER
DIABETES,
HYPERTENSION,
COLON CANCER
FATHER
HEALTHY
GRANDMOTHER
HYPERTENSION
PATIENT
ASTHMA, EXZEMA,
OBESITY
GRANDFATHER
DIABETES,
HYPERTENSION
MOTHER
OBESITY
GRANDMOTHER
ANEMIA

Patient experience of illness

Mom states that she tries to control the fever with over the counter medication, but she felt

impotent when the symptoms persist and she decided to go to the urgent care.

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Previous experience with the health care system

Mom use to go to Montefiores emergency room with her daughter, but now she attend to Essen

Urgent Care and is very satisfied with the services she and her daughter receive in that office.

CURRENT LIFE SITUATION

Patient lives with mother and grandmother in an apartment studio; mom is not working because

she had an accident. Patient spends all weekends with the father that does not work either. Mom

said that both of them are looking for jobs.

HABITS SLEEP

JM sleeps habits are good; mom states she gets 8-9 hours of rest every day.

DIET

JM enjoys eating home cooked food, which consists of variety of vegetables, fish, chicken, and

beef. Her appetite is good and loves to eat at restaurants. She tries to eat healthy food most of the

times, but at times when she is lazy enjoys chips and fast food. Shee has no allergies to any

food.

PLAY/RECREATION

JM practice softball everyday for more than 2 hours. Sometimes she dances at home.

SMOKING

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No history

ALCOHOL

No history

CLIENT PROFILE

MJ is a 10 years old girl who loves to play softball and dance. She is one of the best at school, as

per mother said. She is good at everything, said the mother. When she started something never

stop until is done. She enjoys playing with the grandmother and loves to eat at restaurants. She

also love music and likes to read books.

REVIEW OF SYSTEMS

(Subjective Data The Clients Account)

GENERAL PARAMETER OF HEALTH: JM appears ill and dehydrated. Patient reports, fever,

runny nose shivering, sore throat and nasal congestion.

SKIN: Denies bruising, rashes, or petechial lesions. Denies easy bleeding

HAIR: Denies recent hair loss, change in texture or lice.

NAILS: Denies change in shape, color, brittleness.

HEAD: Denies headaches, head injury, dizziness or vertigo.

NEUROLOGICAL

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MENTAL STATUS: Alert and Oriented. Denies somnolence, disorientation, mood

changes, anxiety, memory disturbance, phobias, hallucinations, depression, inability to

meet responsibilities

CEREBRAL DISTURBANCES: Denies seizures, vertigo or dysphasia.

MOTOR DISTURBANCES: Denies altered gait, coordination difficulty, tremors, paresis

or paralysis

SENSORY DISTURBANCES: Denies anesthesia or paresthesia.

EYES: Denies strabismus, vision changes, blurring, diplopia, pain, redness, swelling,

discharge or cataracts.

Last Vision Exam: 2017, patient uses glasses.

EARS: Denies earaches, infections, discharge. No tinnitus, vertigo or cerumen (wax).

Parents clean the ear weekly with the aid of Q-tips.

NOSE & SINUSES: Hyaline discharge, frequent colds, no pain or obstruction, nasal

congestions, denies nosebleeds. No allergies.

MOUTH & THROAT: Sore throath, hyperemic, no difficulty chewing, dysphagia to

solids, no bleeding gums, hoarseness. Teeth are in good condition, patient brushes her

teeth after each meal. Reports sore throat 4 to 5 times a year.

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o Last dental checkup: 02/2017

Tonsillectomy: No history.

NECK: Denies pain, swollen or tender glands, enlargement, limited movement, lumps or

stiffness.

BREASTS: Denies pain, swelling, enlargement, limitation of movement or dimpling.

o Axillae: Denies tenderness, lumps or swelling

RESPIRATORY: Denies croup, asthma (since 3 years old), no SOB, wheezing, coughing

or sputum production. Denies hemoptysis, exposure to environmental hazards.

CARDIOVASCULAR: Denies murmur, CHD, palpitations, cyanosis or exertional

dyspnea. Patien does not have any activity limitations and is able to keep up with peers.

PERIPHERAL VASCULAR: Denies cyanosis, cold extremities, numbness, pedal

pulses(+++).

GASTROINTESTINAL: Good appetite, denies food intolerance, allergies, dysphagia,

abdominal pain, N&V, diarrhea, constipation. Denies history of ulcers, appendicitis,

colitis, rectal bleeding, change in stools, stool color.

Frequency of BM: Has regular bowel movement every day, no blood or straining at stools

GENITOURINARY: Denies urgency, nocturia, dysuria, polyuria or oliguria, no blood in

urine, enuresis, toilet trained at 2 years old.

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o Female: No menstrual history, vaginal itching, discharge, abnormal bleeding.

Patient is not sexually active.

o Sexuality Sex education awareness. Mom wants to wait to speak about sexuality

with her daughter.

MUSCULOSKELETAL: Denies cramps, swelling, weakness or deformity. No stiffness,

joint pain or swelling. No back pain.

HEMATOLOGIC: Denies bleeding tendency, bruising or lymph node swelling.

o Blood transfusions: No history.

ENDOCRINE: Denies polyuria, polydipsia, polyphagia, heat/cold intolerance, changes in

skin pigmentation or texture, abnormal hair distribution, delayed or precocious puberty

pain.

PHYSICAL EXAMINATION - OBJECTIVE DATA

VITAL SIGNS

B/P 122/83mmHg Pulse/Heart Rate 78/min RR 16/min

Temp 98.9C Weight 151 pounds Height 56 inches Pulse Oximeter 96%

GENERAL SURVEY

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Pediatric Nursing Care Plan

JM is well developed well-nourished, pleasant, cooperative girl and she was in no acute distress.

She is dressed appropriately and well groomed for season and setting.

MENTAL STATUS:

Appearance

JM was lying on the bed, appeared ill but comfortable and relaxed, no abnormal or involuntary

body movements were noted

Behavior

She did not appear distracted and makes appropriate eye contact throughout the encounter. Her

speech was coherent and her articulation was clear and understandable. Word choice was

effortless and appropriate to her age and educational level.

Her mood and affect was appropriate.

Cognitive Function

Alert and oriented to time, place and person. No impairment of recent and remote memory as she

was able to recall what she has for breakfast and past events. She denied any signs and symptoms

of depression and suicidal intent.

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NEUROLOGICAL STATUS

Normal motor and sensory function, intact cerebellar function.

SKIN

No rash, lesions, bruising or rash. Good color, warm, dry, smooth, intact skin with good turgor.

No clubbing, cyanosis, Capillary refill in 2-3 second

EENT

Conjunctiva is clear, sclera is white, PERRLA, External ear canal is clear, no redness, swelling,

lesion or discharge. Nares patent, pink mucosa, no polyps, perforation or septal deviation.

NECK

Neck is supple, no lymphadenopathy, trachea is midline, no bruit, no thyromegaly,

THORAX & LUNGS

Lung sounds clear and equal bilaterally, No tenderness on palpation. Breathing comfortably in

room air. No kyphosis or scoliosis

HEART

Apical pulse is in the 5th Intercostal space, S1S2 normal, regular rate and rhythm, no murmurs.

MUSCULOSKELETAL:

No swelling, masses, no tenderness on palpation of joints, Full ROM in all 4 extremities.

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EXTREMITIES:

No cyanosis, clubbing or edema, peripheral pulses intact.

ABDOMEN

Soft, symmetric, Tenderness in Left upper quadrant, no masses, no organomegaly, no scars or

lesions, Bowel sounds present

GENITOURINARY SYSTEM

Regular bladder movements, no hematuria, no Foley catheter

LIST PERTINENT LAB DATA & DIAGNOSTIC TESTS

04/08/2017

Rapid strep: Negative

Throat culture: Done. Sent to laboratory.

LIST TREATMENTS

Antibiotic as ordered

Gagles or Cloraseptic as ordered

Current Medical Diagnosis

Pharyngitis

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ACUTE PHARYNGITIS

Acute pharyngitis is a sudden painful inflammation of the pharynx, the back portion of the throat

that includes the posterior third of the tongue, soft palate, and tonsils. It is commonly referred to

as a sore throat. In the United States, it is estimated that approximately 11 million people

experience pharyngitis each year. Because of environmental exposure to viral agents and poorly

ventilated rooms, the incidence of viral pharyngitis peaks during winter and early spring in

regions that have warm summers and cold winters. Viral pharyngitis spreads easily in the

droplets of coughs and sneezes and unclean hands that have been exposed to the contaminated

fluids.

Pathophysiology

Viral infection causes most cases of acute pharyngitis. Responsible viruses include the

adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus. Bacterial infection

accounts for the remainder of cases. Ten percent of adults with pharyngitis have group A beta-

hemolytic strepococcus (GABHS), which is commonly referred to as group A streptococcus

(GAS) or streptococcal pharyngitis. Streptococcal pharyngitis warrants use of antibiotic

treatment. When GAS causes acute pharyngitis, the condition is known as strep throat. The body

responds by triggering an inflammatory response in the pharynx. This results in pain, fever,

vasodilation, edema, and tissue damage, manifested by redness and swelling in the tonsillar

pillars, uvula, and soft palate. A creamy exudate may be present in the tonsillar pillars. Other

bacterial organisms implicated in acute pharyngitis include Mycoplasma pneumoniae, Neisseria

gonorrhoeae, and H. influenzae type B (Braun, Wagner, Huttner, et al., 2006). M. pneumoniae is

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Pediatric Nursing Care Plan

one of the most common known bacterial pathogens of the respiratory tract and is encountered

frequently in people with upper respiratory symptoms.

Uncomplicated viral infections usually subside promptly, within 3 to 10 days after the onset.

However, pharyngitis caused by more virulent bacteria, such as GAS, is a more severe illness. If

left untreated, the complications can be severe and life-threatening. Complications include

sinusitis, otitis media, peritonsillar abscess, mastoiditis, and cervical adenitis. In rare cases, the

infection may lead to bacteremia, pneumonia, meningitis, rheumatic fever, and nephritis.

Epidemiology. Prevalence. The average incidence of all acute URIs is five to seven per

child per year. It is estimated that children have one streptococcal infection every 4 to 5 years.

Group A streptococci is isolated in 30-36.8% of children with pharyngitis.

Age Occurrence. Pharyngitis is infrequent in the first 2 years of life, when all URIs are

most frequent. Most cases of pharyngitis occur in school-age children, when the incidence of all

infections is still high but less than in the first 2 years.

Clinical Manifestations

The signs and symptoms of acute pharyngitis include a fiery-red pharyngeal membrane and

tonsils, lymphoid fol- licles that are swollen and flecked with white-purple exudate, enlarged and

tender cervical lymph nodes, and no cough. Fever (higher than 38.3 C [101 F]), malaise, and sore

throat also may be present. Occasionally, patients with GAS pharyngitis exhibit vomiting,

anorexia, and a scarlatina-form rash with urticaria known as scarlet fever.

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People who have streptococcal pharyngitis suddenly develop a painful sore throat 1 to 5 days

after being ex- posed to the streptococcus bacteria. They usually report malaise, fever (with or

without chills), headache, myalgia, painful cervical adenopathy, and nausea. The tonsils appear

swollen and erythematous, and they may or may not have an exudate. The roof of the mouth is

often erythematous and may demonstrate petechiae. Bad breath is common.

Nursing Management

Nursing care for patients with viral pharyngitis focuses on symptomatic management. For

patients who demonstrate signs of strep throat and have a history of rheumatic fever, who appear

toxic, who have clinical scarlet fever, or who have symptoms suggesting peritonsillar abscess,

nursing care focuses on prompt initiation and correct administration of prescribed antibiotic

therapy. The nurse instructs the patient about signs and symptoms that warrant prompt con- tact

with the physician. These include dyspnea, drooling, inability to swallow, and inability to fully

open the mouth.

The nurse instructs the patient to stay in bed during the febrile stage of illness and to rest

frequently once up and about. Used tissues should be disposed of properly to pre- vent the spread

of infection. The nurse (or the patient or family member, if the patient is not hospitalized) should

ex- amine the skin once or twice daily for possible rash, because acute pharyngitis may precede

some other communicable diseases (eg, rubella).

Depending on the severity of the pharyngitis and the degree of pain, warm saline gargles or

throat irrigations are used. The benefits of this treatment depend on the degree of heat that is

applied. The nurse teaches the patient about these procedures and about the recommended

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temperature of the solution: high enough to be effective and as warm as the patient can tolerate,

usually 40.6 C to 43.3 C (105 F to 110 F). Irrigating the throat may reduce spasm in the

pharyngeal muscles and relieve soreness of the throat.

An ice collar also can relieve severe sore throats. Mouth care may promote the patients comfort

and prevent the development of fissures (cracking) of the lips and oral inflammation when

bacterial infection is present. The nurse instructs the patient to resume activity gradually and to

delay returning to work or school until after 24 hours of antibiotic therapy. A full course of

antibiotic therapy is indicated in patients with strep infection because of the potential

complications such as nephritis and rheumatic fever, which may have their onset 2 or 3 weeks

after the pharyngitis has sub- sided. The nurse instructs the patient and family about the

importance of taking the full course of therapy and informs them about the symptoms to watch

for that may indicate complications.

In addition, the nurse instructs the patient about preventive measures that include not sharing

eating utensils, glasses, napkins, food, or towels; cleaning telephones after use; using a tissue to

cough or sneeze; disposing of used tis- sues appropriately; and avoiding exposure to tobacco and

secondhand smoke. The nurse also teaches the patient with pharyngitis, especially streptococcal

pharyngitis, to replace his or her toothbrush with a new one.

MEDICATION

Albuterol (Proventil, Ventolin). Nebulizer (0.083%)

Short-acting beta2-agonists are bronchodilators. They relax the muscles lining the airways that

carry air to the lungs; treatment of choice for acute exacerbation of asthma.

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Therapeutic Effects: Bronchodilation.

Adverse Reactions/Side Effects

CNS: nervousness, restlessness, tremor, headache, insomnia (Pedi: occurs more frequently in

young children than adults), hyperactivity in children. Resp: PARADOX- ICAL

BRONCHOSPASM (excessive use of inhalers). CV: chest pain, palpitations, angina,

arrhythmias, hypertension. GI: nausea, vomiting. Endo: hyperglycemia. F and E: hypokalemia.

Neuro: tremor

NURSING IMPLICATIONS

Assess lung sounds, pulse, and BP before administration and during peak of medication.

Note amount, color, and character of sputum produced.

Monitor pulmonary function tests before initiating therapy and periodically during therapy.

Observe for paradoxical bronchospasm (wheezing). If condition occurs, withhold

medication and notify health care professional immediately.

Fluticasone (Flovent). Aerosol inhaler. 88 mcg twice daily

Corticosteroids reduce inflammation in the airways that carry air to the lungs and reduce the mucus

made by the bronchial tubes. Inhaled steroids should be given after beta-2-adrenergic agonist.

Therapeutic Effects: Decrease in symptoms of allergic and no allergic rhinitis.

Adverse Reactions/Side Effects

CNS: headache. EENT: epistaxis, nasal burning, nasal irritation, nasopharyngeal fungal infection,

pharyngitis. GI: nausea, vomiting. Endo: adrenal suppression (increase dose, long-term therapy

only),decrease growth (children). Derm: rash, urticaria. Resp: cough.

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NURSING IMPLICATIONS

Monitor degree of nasal stuffiness, amount and color of nasal discharge, and frequency

of sneezing.

Patients on long-term therapy should have periodic otolaryngology examinations to

monitor nasal mucosa and passages for infection or ulceration.

Monitor growth rate in children receiving chronic therapy; use lowest possible dose.

Monitor for signs and symptoms of hypersensitivity reactions (rash, pruritus,

swelling of face and neck, dyspnea) periodically during therapy.

Amoxicillin 500 mgrs p.o. every 8hrs daily, during 10 days. (Medication given base on

criteria. Patient score was 4).

Derivative of ampicillin and has similar antibacterial spectrum (certain gram-positive and gram-

negative organisms); similar bactericidal action as penicillin; acts on susceptible bacteria during

multiplication stage by inhibiting cell wall mucopeptide biosynthesis; superior bioavailability and

stability to gastric acid and has broader spectrum of activity than penicillin; less active than

penicillin against Streptococcus pneumococcus; penicillin-resistant strains also resistant to

amoxicillin, but higher doses may be effective; more effective against gram-negative organisms

(eg, N meningitidis, H influenzae) than penicillin.

Therapeutic Effects: Bactericidal action; spectrum is broader than penicillins.

Adverse Reactions/Side Effects

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CNS: SEIZURES (high doses). GI: PSEUDOMEMBRANOUS COLITIS, diarrhea, nausea,

vomiting, increase liver enzymes. Derm: rash, urticaria. Hemat: blood dyscrasias.

NURSING IMPLICATIONS

Assess for infection (vital signs; appearance of wound ,sputum, urine, and stool; WBC)

at beginning of and throughout therapy.

Obtain a history before initiating therapy to determine previous use of and reactions to

penicillins or cephalosporins. Persons with a negative history of penicillin sensitivity may still

have an allergic response.

Observe for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema,

wheezing). Notify health care professional immediately if these occur.

Obtain specimens for culture and sensitivity prior to therapy. First dose may be given

before receiving results.

Monitor bowel function.

MUTUALLY ID CONCERNS

Nutrition (diet). JM is an overweight girl who loves to eat, especially on

restaurants.

Parental Separation and care of the patient.

Medications

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STRENGTH and RESOURCES

Per Mother statement, she has good family support system. She is also a friendly girl, who

has a lot of peers. She practice softball everyday and sports serve as a therapy.

She identifies prayer and spiritual activities are a major coping strategy. She believes in God and

prays regularly so she is confident that she will be able to achieve his aims and goals in life.

Strength:

Parent support

Peer

Play therapy

Resources:

Social Services from parents

Religious affiliation

School peers

Patient/family educational needs:

Medication

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Diet

Exercise

Oral hygiene

Monitor Vital Signs, specially RR and Temperature.

Discharge planning needs

Teaching about the disease process

Medication administration

Follow up appointments

Teach the mother how to use the thermometer

Seek care immediately if:

Your child suddenly has trouble breathing or turns blue.

Your child has swelling or pain in his jaw.

Your child has voice changes, or it is hard to understand his speech.

Your child has a stiff neck.

Your child has increased weakness or fatigue.

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Your child has pain on one side of his throat that is much worse than the other side.

Manage your child's pharyngitis:

Have your child rest as much as possible.

Give your child plenty of liquids so he does not get dehydrated. Give him liquids that

are easy to swallow and will soothe his throat.

Soothe your child's throat. If your child can gargle, give him of a teaspoon of salt

mixed with 1 cup of warm water to gargle. If your child is 12 years or older, give him

throat lozenges to help decrease his throat pain.

Use a cool mist humidifier to increase air moisture in your home. This may make it

easier for your child to breathe and help decrease his cough.

Help prevent the spread of pharyngitis:

Wash your hands and your child's hands often. Keep your child away from other people while he

is still contagious. Ask your child's healthcare provider how long your child is contagious. Do

not let your child share food or drinks. Do not let your child share toys or pacifiers. Wash these

items with soap and hot water.

When to return to school or daycare:

Your child may return to daycare or school when his symptoms go away.

NURSING DIAGNOSES

1. Altered comfort related to pain in throat

2. Altered thermoregulation related to inflammatory process

3. Knowledge deficit related to disease process

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REFERENCES

Braun, G., Wagner, K., Huttner, B., et al. (2006). Mycoplasma pneumoniae: Usual suspect and
unsecured diagnosis in the acute setting. Journal of Emer- gency Medicine,
30(4), 371375.

Herdman, H. T., & Kamitsuru, S. (2014). Nursing diagnoses 2015-2017 definitions and
classification. Oxford: Wiley.

Hockenberry, M. J. & Wilson, D. (2011). Wongs Nursing Care of Infants and Children (9th
ed.). Philadelphia, PA: FA Davis Company.

Jarvis, C. (2012). Physical examination and health assessment (6th ed). Saunders.

McKinney, E. S. (2012). Maternal-child nursing (4th Ed.). St. Louis, Missouri:

Elsevier/Saunders.

Skidmore-Roth, L. (2011). Mosby's drug guide for nurses. St. Louis, MO: Mosby Inc.

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Twycross, A., Dowden, S., & Bruce, E. (2009). Managing pain in children a clinical guide.
Ames, IA: Wiley-Blackwell.

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