Javier, Jomar A. BSN121 Group 83

Nursing Care Plan(Pediatric Patient)

Nursing Diagnosis/ Cues

Analysis Goal and Objectives

Intervention Rationale Evaluation

Diarrhea r/t infectious process secondary to Acute Gastroenteritis

Subjective: The mother

stated “simula palang nung na admit kami dito nung lunes eh nagtatae na talaga siya”

She also added: “naawa na nga ako sa kanya kasi maya’t maya ay nagpapalit kami ng diaper, baka nga magka-irritation siya sap wet dahil dun”

“Umiiyak siya minsan at nagcocomplain siya na masakit tiyan niya”

Objective: Changed

diaper 3x with

Scientific:Passage of loose, unformed stools pathogens cause tissue damage and inflammation by releasing endotoxins that stimulate the mucosal lining of the intestine resulting in the greater secretion of water and electrolytes into the intestinal lumen. The active secretions of chloride and bicarbonate ions are the small bowel leads to the inhibition of sodium re-absorption. To balance the excess sodium, large amounts of protein rich foods fluids are secreted in the bowel’s ability to reabsorb the fluid and leading to

Goal:After 4 days of nursing interventions, the patient will reestablish and maintain normal pattern of bowel functioning.

Objectives: After 1 hour of

discussion, the parent will verbalize understanding causative factor and rationale for treatment regimen.

After 1 hour of discussion, the parent will demonstrate appropriate behavior to assist with resolution of causative factors (e.g., proper food preparation, or

Independent: Restrict solid

food intake, as indicated

Provide for changes in dietary intake

Limit caffeine and high fiber foods; avoid milk and fruits, as appropriate

Assess for presence of postural hypotension, tachycardia, skin hydration/turgor, condition of mucous membranes

Weigh infant’s diapers

Encourage oral

To allow for bowel rest/reduced intestinal workload

To avoid foods/ substances that precipitate diarrhea

It stimulates gastric motility

Indicating hydration

To determine amount of output and fluid replacement needs

After 4 days of nursing interventions, the patient reestablished and maintained normal pattern of bowel functioning.

After 1 hour of discussion, the parent verbalized understanding causative factor and rationale for treatment regimen.

After 1 hour of discussion, the parent demonstrated appropriate behavior to assist with resolution of causative factors (e.g., proper food preparation, or avoidance of irritating foods)

loose and deformed stools

Abdominal distention noted upon palpation

Upon auscultation, hyperactive bowel sounds noted.

Irritated and crying.

diarrhea.

Situational: As for the patient, the causative factor of her diarrhea is her disease (Acute Gastroenteritis)

avoidance of irritating foods)

intake of fluids containing electrolytes, such as juices, bouillon, or commercial preparation as appropriate.

Assist, as needed, with pericare after each bowel movement.

Provide prompt diaper change and gentle cleansing

Apply lotion/ointment or petroleum jelly as skin barrier, as needed.

Provide dry linen, as necessary.

Expose perineum/ buttocks to air; use heat lamp with caustion, if needed.

To promote return to normal bowel functioning Increase oral

fluid intake and

Because skin breakdown can occur quickly when diarrhea is present.

To keep the area dry because moisture can adhere skin breakdown

return to normal diet, as tolerated.

Encourage nonirritating liquids.

Discuss possible change in infant formula.

Recommend products such as natural fiber, plain natural yogurt, Lactinex.

Promote wellness

Review causative factors and appropriate interventions.

Evaluate/identify individual stress factors and coping behavior.

Review food preparation, emphasizing adequate cooking time and proper refrigeration/storage.

Diarrhea maybe result of aggravated by intolerance to specific formula.

To restore normal flora

To prevent diarrhea from recurring

To prevent bacterial growth/ contamination

To prevent spread infectious causes of diarrhea such as C. defficile or S.

Emphasize the importance of hand washing.

Dependent: Assist in

treatment of underlying conditions (e.g., infections, malabsorption syndrome, and cancer) and complications of diarrhea.

Review laboratory studies for abnormalities.

Administer enteral and IV fluids as indicated.

Administer anti-diarrheal medications, as indicated

Administer medications, as ordered.

aureus

Therapies can include treatment of fever, pain, and infectious toxic agents, rehydration, and oral feeding, etc.

To decrease gastrointestinal motility and minimize fluid losses.

To treat infectious process, decrease motility, and/or absorb water.

Nursing Diagnosis/ Cues

Analysis Goal and Objectives

Intervention Rationale Evaluation

Impaired oral mucous membrane r/t trauma

Subjective: The mother

state: “Me singaw siya sa bibig, minsan umiiyak siya pag pinpapakain ko siya at minsan dinudura niya at umiiyak”

Objective: Single

ulceration on the mucosal wall noted.

Goal:After 5 days of nursing interventions, the patient will show a decrease in signs and symptoms as noted in defining characteristics.

Objectives: After 2 hours

of discussion, the parent will verbalize understanding of causative factors.

After 2 hours of discussion, the parent will demonstrate

Independent: Routinely

inspect oral cavity and throat for inflammation, sores, lesions, and/or bleeding. Determine if patient is experiencing pain or painful swallowing.

Encourage adequate fluids.

Provide dietary modifications (e.g., food of comfortable

To prevent dry mouth and dehydration.

To reduce discomfort/ improve intake and promote healing

techniques to restore/maintain integrity of oral mucosa.

texture, temperature, density) and adequate nutrients and vitamins.

Avoid irritating foods/fluids, temperature extremes; provide soft or pureed diet as required.

Assist/ provide oral care, as indicated.

Review current oral hygiene patterns and provide information about oral health as required/desired.

Instruct parents in oral hygiene techniques and proper dental care for infants/children (e.g., use of

To correct deficiencies and encourage proper care.

Encourage early initiation of good oral health practice and timely intervention for treatable problems.

pacifier, brushing of teeth and gums, avoidance of teeth and gums, avoidance of sweet drinks and candy, recognition and treatment of thrush.)

Promote general/ mental health.

Provide nutrional information.

Stress importance of limiting night time regimen of bottle of milk for infant in bed. Suggest pacifier or use of water during night.

Altered immune response can affect the oral mucosa.

To correct deficiencies, reduce irritation/ gum disease, prevent dental carries.

To prevent bottle syndrome with decaying of teeth.

When infection is present

Dependent: Administer

antibiotics, as ordered

Review information regarding drug regimen , use of local anesthetics.