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/SelfConcept; 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. 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. 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. Patient has become less active especially during occurrences of pneumonia. 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.

Ø

Role/Relationship:

Ø Nutrition/Metabolic:

Ø Activity/Exercise:

Ø Cognitive/Perceptual:

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

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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.

Nursing Diagnosis

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 • •

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(,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)
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Insert a nasogastric, nasoduodenal, or nasojejunal tube, according to agency protocol

Applying anchoring substance to skin, and secure feeding tube with tape

Request that tube placement be checked by xray 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

Monitor for presence of bowel sounds every 4 to 8 hr., as appropriate Elevate head of the bed during feedings

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

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

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

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NOC-Nutritional Status: Energy NIC: Weight Gain Assistance-Activities (,p.703)
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Refer for diagnostic workup to determine cause of being underweight, as appropriate Monitor for nausea and vomiting Monitor daily calories consumed Instruct on how to increase calorie intake

Weigh patient at specified intervals, as appropriate

Discuss possible causes of low body weight

Determine cause of nausea and/or vomiting, and treat appropriately Monitor serum albumin, lymphocyte, and electrolyte levels Provide a variety of highcalorie nutritious foods from which to select Provide rest periods, as needed Provide foods appropriate for patient: general diet, mechanical soft, blenderized or commercial formula via nasogastric or gastrostomy tube, or total parental nutrition, as ordered by physician Discuss with patient and family socioeconomic factors contributing to inadequate nutrition Teach patient and family meal planning, as appropriate

Administer medications to reduce nausea and pain before eating, as appropriate Encourage increased calorie intake

• •

Provide oral care before meals, as needed Assist with eating or feed patient, as appropriate

• •

• •

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

Serve food in a pleasant, attractive manner

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

Refer to community agencies that can assist in acquiring food, as appropriate Reward patient for weight gain

Chart weight gain progress and post in a strategic location

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

Weigh patient at specified intervals Monitor patient’s emotional response when placed in situations that involve food and eating Schedule treatments and procedures at times other than feeding times Monitor for dry, thin hair that is easy to pluck Monitor skinfold measurements;triceps skinfold, midarm muscle circumference, and midarm circumference Monitor food preferences and choices Monitor for pale, reddened, and dry conjunctival tissue Monitor for redness, swelling, and cracking of mouth/lips Note significant changes in nutritional status and initiate treatments, as appropriate Provide optimal environmental conditions at mealtime

• •

Monitor trends in weight loss and gain Monitor parent/child interactions during feeding, as appropriate Monitor for dry, flaky skin with depigmentation Monitor gums for swelling, sponginess, receding, and increased bleeding Monitor albumin, total protein, hemaglobin, and hematocrit levels

• •

Monitor type and amount of usual exercise Monitor environment where eating occurs

Monitor skin turgor, as appropriate

Monitor for nausea and vomiting

Monitor lymphocyte and electrolyte levels

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• •

Monitor growth and development Monitor caloric and nutrient intake Note any sores, edema, hyperemic and hypertrophic papillai of the tongue and oral cavity Initiate a dietary consult, as appropriate

• •

Monitor energy level, malaise, fatigue, and weakness Monitor for spoon-shaped, brittle, ridged nails Note if tongue is scarlet, magenta, or raw

Determine whether the patient needs a special diet

Provide nutritional food and fluid, as appropriate

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

Congratulations!

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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)

Nutritional Status: Food & Liquid Intake

Measurement Scale Score: 1 = Not adequate 2 = Slightly adequate 3 = Moderately adequate 4 = Substantially adequate 5 = Totally adequate

❏ Oral food intake ❏ Tube feeding intake ❏ Oral fluid intake ❏ IV fluid intake DATE/TIME INITIALS

Nutritional Status: Energy

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

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NICs (interventions)ACTIVITIES:
MODIFICATIONS:

Fluid Management
MODIFICATIONS:

❑ ❑ ❑ ❑ ❑

DATE/TIME

ACTIVITIES:

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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