ASSESSMENT Subjective: Magaling na ko uuwi na ko..

sa bahay as verbalized by the client Baka pauuwiin na kami sabi ata ng nurse eh.. as verbalized by the client s mother Objective: -client is ambulatory (accompanied by mother) -On D5IMB 1,200 ml x 24hrs. (discontinued at around 8:30pm) -V/S taken as follows: T- 36.8 BP-90/60 RR-22 PR-110

DIAGNOSIS Readiness for enhanced home maintenance management related to improving health status

INFERENCE Following 2 days of hospitalization due to ingestion of excessive amounts of ascorbic acid, client showed no signs of deterioration of health and appeared stable during the entire shift. An early discharge is likely, therefore plans for continued health management at home is necessary in order to prevent future occurrences.

PLANNNING After 1 hour of nursing intervention: y The client s mother will verbalize understanding of importance of continued health maintenance and supervision. y The mother will be provided with health teachings regarding safe storage of medication, effects of drug toxicity/overdos e, etc.

INTERVENTIONS
Independent: y Assess client s vital signs

RATONALE
y To monitor changes in client s health status. y Client may get fidgety as children his age are usually highly active physically especially as his condition improves. y Continued monitoring is necessary to prevent possible development of complications (possible kidney stone formation) y Discussing its effects may encourage parent to efficiently monitor client at home to prevent similar incidents. y Numerous references, such as books or personal consultations are available regarding

EVALUATION Goal met. As evidenced by: - Client s parent/s verbalized and understood discharge needs of the client.

y Allow client to rest and stay in bed. Keep side rails up

y Discuss with mother discharge needs and home care. Instruct to report signs of bleeding (hematuria) and abdominal pain y Provide information regarding complications of vitamin c toxicity

y Provide suggestions to the parent for sources of support that will help reinforce

enhanced behaviors on the child. y Emphasize importance of home adult supervision.

disciplinary measures in proper guidance of children. y Supervision is necessary to direct children s curiosity in the proper direction.

Dependent: y Administer indicated medication (Famotidine TIV q 12hours) y Instruct client on proper taking of prescribed home meds y Decreases risk of gastric irritation.

y For continued therapeutic management.

ASSESSMENT Subjective: kinain ko yung Celine (referring to vitamin c tablets 100mg) na madami.. masarap parang candy as verbalized by client nakarami kasi siya ng kinain di ko alam kung baka ano mangyari kaya dinala naming dito as verbalized by mother Objective: -On D5IMB 1,200ml for 24hrs. -V/S taken as follows: T- 36.8 BP-90/60 RR-22 PR-110

DIAGNOSIS Knowledge, deficit related to cognitive limitation (age of 4yrs), lack of exposure, misinterpretation of information

INFERENCE
Lack of information hinders effective nurse-patient communication which thereby affects the quality of rendered care; therefore, Provision of sufficient and accurate details regarding the disease process or the procedures being undertaken for its treatment presents a better perception of the condition and results in a more interactive and cooperative nurse- patient relation. Since this is a pediatric client, appropriate education of the client should be provided by the parents.

PLANNNING After 1 hour of nursing intervention: y The client s parent will verbalize understanding of the disease process and complications. y The client will be provided with information on his condition in a manner appropriate to his age and level of intellect.

INTERVENTIONS
y Monitor client s vital signs

RATONALE
y May serve as initiation of NPI and nurse-patient trust development. y Development of client s confidence in one s nursing care is founded by effective and interactive communication. y Pediatric clients can be easily distracted therefore a lively impression will gain his focus and attention.

EVALUATION Goal met. As evidenced by: - Client and parent verbalized understanding of the condition. - The client and parent expressed approval and cooperation regarding therapy and maintenance of health.

y Establish rapport and engage in a casual conversation with client and mother y Develop a relaxed and pleasant atmosphere by infusing humor in conversations with client and speaking in a natural tone of voice. y Assess client s or parent s perception of his health condition y Correct the client s wrong perceptions in a manner that is constructive, non-judgmental, and ageappropriate.

y To know how much information is needed for necessary corrections. y To emphasize a mistake has been made while not giving the client a negative impression which may yield a negative response.

y Inform the parent on the possible complications of vitamin c toxicity y Allow parent to discuss additional matters regarding his condition with his child

y Discussing its effects may encourage parent to efficiently monitor client.

y Nothing can convince or encourage a child more than the words of his mother or father.

Dependent: y Administer indicated medication (Famotidine TIV q 12hours) y Instruct client on proper taking of prescribed home meds

y Decreases risk of gastric irritation.

y For continued therapeutic management