Nutrition imbalanced less than body requirements related to inadequate food intake Delayed growth and development: language r/t inadequate stimulation. Knowledge deficit related to cognitive limitation as evidence by questions and statements of concern Risk for injury related to sudden, abnormal, and excessive electrical discharges from the brain. Risk for aspiration related to sudden, abnormal, and excessive electrical discharges from the brain. Ineffective Family Coping related to Seasonal Work

Nutrition imbalanced less than body requirements related to inadequate food intake

Subjective:
-³saging lang iya ginakaon´as verbalized by the mother.

Objective:
Weight: 10.3 kg Height: 32 inches BMi: 16.6 (underweight) Hgb=127(dehydration) dry and blonde hair pale conjunctiva irritable restless

NCP

NCP .Nutrition imbalanced less than body requirements related to inadequate food intake After 2-3 hours of nursing intervention: The mother will verbalize understanding of nutritional needs The mother will demonstrate selection or meals that will achieve a cessation of weight loss.

Patient Mother perception of actual intake may differ Proper assessment guides information To stimulate appetite and promote interest in eating.Nutrition imbalanced less than body requirements related to inadequate food intake Nursing Interventions (Independent and Dependent) Independent Document actual weight and height. Advice the mother to serve food and fluids those are appealing to the client. Rationale Independent Patient mother may be unaware of the actual height and weight loss of his child due to estimating weight. NCP . Obtain nutritional history Monitor or explore attitudes toward eating and food.

NCP .Nutrition imbalanced less than body requirements related to inadequate food intake Nursing Interventions (Independent and Dependent) Therapeutic Discourage beverages that are caffeinated or carbonated. Engage the patient to a healthy physical activities Rationale Therapeutic These may decrease appetite and lead to early satiety. Metabolism and utilization of nutrients are enhanced by activity.

NCP . The mother made a resolve to prepare nutritious yet affordable food or meals.Nutrition imbalanced less than body requirements related to inadequate food intake After 2-3 hours of nursing intervention: The mother verbalized understanding her son¶s nutritional needs.

Papa. Dede kag Wewe palng sina iya namitlangan gha´as verbalized by the mother.Delayed growth and development: language r/t inadequate stimulation. Lack of time by the mother. Objective: 3 year-old older sibling. Subjective: ³Bale Mama. Pointing on something he wants. NCP .

NCP . and functional age. extent of disability.Delayed growth and development: language r/t inadequate stimulation. Within the hospitalization days the patient will achieve realistic developmental and growth milestone based on existing abilities.

Engage the child in appropriate play activities and offer them the appropriate toys.Delayed growth and development: language r/t inadequate stimulation. Nursing Interventions (Independent and Dependent) Provide meaningful stimulation by initiating conversation to the client. Frequent and consistent family contact and care promotes emotional assurance to the child and thus promotes conversation. NCP . Play is essential for learning in children and it is also a means of communicating to them. Rationale Initiating a conversation is a type of stimulation and it is essential to the development of the language of the child. Enlist and encourage involvement of the parents and/or family as participants in the care of the child particularly in the hospital.

Delayed growth and development: language r/t inadequate stimulation. Rationale Parents may be distress by the potential for development delay of the child. Parents are then better equipped to promote the growth and development of the child. NCP . Nursing Interventions (Independent and Dependent) Provide emotional support for family members in their reactions to evidence of developmental delay. and safety. nutrition. Instruct the mother with regard to age-appropriate activities and play. discipline. and hoe to support growth and development.

Papa. wewe.Delayed growth and development: language r/t inadequate stimulation. Goal was not met. The patient still unable to utter other words beside Mama. NCP . and dede.

NCP .Knowledge deficit related to cognitive limitation as evidence by questions and statements of concern Subjective: ³Ano inang seizure nga gina tawag nila man?´ as verbalized by the mother.

Knowledge deficit related to cognitive limitation as evidence by questions and statements of concern After 3-4 hours of nursing intervention: The mother can verbalize understanding of disorder and various stimuli that may increase seizure activity. The mother can express a desire for necessary lifestyle/behavior changes as indicated. NCP .

hyperventilation. Emphasize the importance of good oral hygiene and regular dental care.g. loud noises. enhancing sense of general well being. Regularity and moderation in activities may aid in reducing/ controlling precipitate factors.Knowledge deficit related to cognitive limitation as evidence by questions and statements of concern Nursing Interventions (Independent and Dependent) Independent Discuss the pathology/ prognosis of condition and lifestyle need for treatment as indicated. and strengthening coping ability and self esteem. Rationale Provides opportunity to clarify/dispel misconception and present condition as something that is manageable within a normal lifestyle. and video games. Reduces risk of oral infections and gingival hyperplasia. And Explain the importance of maintain good general health. NCP . flashing lights. Discuss patient particular trigger factors (e.

NCP .Knowledge deficit related to cognitive limitation as evidence by questions and statements of concern Goal met After 3-4 hours of nursing intervention: The mother verbalized understanding of disorder and various stimuli that may increase seizure activity. The mother expressed a desire for necessary lifestyle/behavior changes as indicated.

Subjective: ³Gin hilanat siya kag nag turong iya mata´ as verbalized by the mother. abnormal.Risk for injury related to sudden. NCP . and excessive electrical discharges from the brain. Objective: History of seizure episodes.

Risk for injury related to sudden. abnormal. bruises or fractures present. No limitation in movement. The patient will be free from injury within the succeeding days of hospitalization as manifested by: Intact skin No pain. NCP . and excessive electrical discharges from the brain.

To avoid patient from injury and promote safety. Rationale A tongue depressor will prevent oral trauma. Turn head to side. To maintain patent airway. and excessive electrical discharges from the brain. abnormal. To promote client safety. NCP . Maintain bed in lowest position with wheels locked. Encouraged bed rest. To prevent fatigue and promote healing. Nursing Interventions (Independent and Dependent) Independent: Seizure precautions Prepare a tongue depressor at bedside Pad the side of the crib w/ blankets or pillows.Risk for injury related to sudden.

Loosen tight clothing. and characteristic of seizure activity and any post seizure response. Observe for. as appropriate. To maintain patent airway. duration. Characteristic of seizure and post seizure response should include. NCP . initial location and progression. Roll patient into a side-lying position. To prevent injury caused by flailing. record. Used head-chin-lift maneuver.Risk for injury related to sudden. To prevent injury caused by constrictive clothing. aura. and excessive electrical discharges from the brain. Nursing Interventions (Independent and Dependent) During the seizure y Remain w/ patient. Rationale Seizure activity should be documented in detail to aid in management and differentiation of seizure type and identifying of triggering factors. and report type. y y y Do not restraint the patient but rather guide patient movements gently. precipitating event. abnormal.

and allow for lower dosage to reduce side effects. NCP .Risk for injury related to sudden. and excessive electrical discharges from the brain. and allow for lower dosage to reduce side effects. abnormal. May be given in emergent situation to potentiate/enhance affects of other Anti-epileptic drugs. Rationale y Monitor complete blood count. May be given in emergent situation to potentiate/enhance affects of other Anti-epileptic drugs. Nursing Interventions (Independent and Dependent) Dependent y Administer Phenobarbital 5mg/pptab 1pptab q 12 hours as ordered by the physician. electrolytes and glucose levels.

abnormal. Goal met As manifested by : Intact skin No pain. bruises or fractures present.Risk for injury related to sudden. NCP . and excessive electrical discharges from the brain. No limitation in movement.

Objective : History of seizure episodes. abnormal. and excessive electrical discharges from the brain. Subjective: ³ Gin hilanat siya kag nag turong iya mata´ as verbalized by the mother. NCP .Risk for aspiration related to sudden.

The patient will be free from aspiration within the succeeding days of hospitalization as manifested By: Noiseless respirations Clear breath sounds No secretion noted. NCP . and excessive electrical discharges from the brain.Risk for aspiration related to sudden. abnormal.

abnormal.(high fowlers position) Assess pulmonary status for clinical sign of aspiration. Provide soft foods. Nursing Interventions (Independent and Dependent) Independent : Elevate client to highest or best possible position for eating and drinking.Risk for aspiration related to sudden. and excessive electrical discharges from the brain. Aspiration of small amounts can occur w/o coughing or sudden onset of respiratory distress. NCP . Auscultate breath sounds for development of crackles and/ wheezes. especially in patients w/ a decreased level of consciousness To prevent aspiration. Rationale To reduce risk For aspiration.

Risk for aspiration related to sudden. abnormal. Goal met As manifested by: Noiseless Respirations Clear breath sounds No secretions noted NCP . and excessive electrical discharges from the brain.

Ineffective Family Coping related to Seasonal Work Subjective: ³Wala permanente nga ubra akon bana.000 NCP .´ As verbalized by the mother. Housewife man lang ko. Objective: Monthly income is below P5. Kulang pa gid sa amon iya sweldo.

the family should be able to express understanding of the problem and identify resources.Ineffective Family Coping related to Seasonal Work After 2 hours of Nursing intervention. NCP .

expectations. a variety of strategies may be required to facilitate coping. and current support systems. Evaluate strengths coping skills. This facilitates the use of previously successful techniques. Resolution is possible only if each person¶s perception is understood. fears. Provide opportunities to express concerns. Rationale Depending on the stressor.Ineffective Family Coping related to Seasonal Work Nursing Interventions (Independent and Dependent) Assess family members¶ perception of problem. or questions. This promotes communication and support. NCP .

. The family was able to express and understand the problem and identified resources.Ineffective Family Coping related to Seasonal Work Goal met.

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