S.No. Nursing assessment 1.

Patient is on mechanical ventilation, no self respiratory effort On SIMV mode , PEEP - 8 cm H2O,PIP- 24cm H2O , I:E- 1:2 RR:46/min

Nursing Dx.

Expected outcome Planning

Nursing Interventions Implementations

evaluation

Altered breathing pattern R/T disease condition

Patient will have clear airway

Assess the respiratory status

Respiratory status assessed Maintains clear airway & demonstrates

Provide proper positioning

Prone position given

appropriate breath sounds

Perform suctioning

Before & after suctioning preoxygenate with 100% oxygen. Oral & ET

Perform chest physiotherapy

suctioning done.

Chest physiotherapy done during suctioning

shoulder support. Bed sore present on right pinna of ear Nursing Dx. Expected outcome Planning Nursing Interventions Implementations Condition of the skin assessed Evaluation Risk for impaired skin integrity R/T immobility Patient will have healing bed sore No redness at bony Assess the skin condition Maintain normal skin integrity Frequent position changing Change the position of patient every 2 hourly. Nursing assessment 2. gloves filled with water provided Dressing of bed sore Bed sore dressing done with betdine followed by Neosporin .No.S. prominence Provide comfort measures Cotton rings.

S. Nursing assessment 3.No. debris present on eye Nursing Dx. Absent corneal reflex. Expected outcome Planning Nursing Interventions Implementations The condition of eyes asssessd evaluation Impaired tissue integrity of cornea R/T to diminished or absent corneal reflex Patient will have no corneal abrasion and redness Assess the condition of eyes Has no corneal irritation Cleanse the eyes Administer artificial tears Eyes are cleansed with cotton balls moistened with normal saline Lacrigel ointment instilled as prescribed Cover eye with eye patches Eye patches are used to cover eyes .

S. Expected outcome Planning Nursing Interventions Implementations Vital sign assessed T37˚C P-112/min R30/min Assess child’s evaluation Potential alteration in body temperature R/T fluid volume deficit / IV administration / unknown reason Body Attainment of normal body temperature temperature physiologic status remains in normal range Provide stable environment temperature Stable environmental temp provided Provide app. Child exhibits frequent changes in body temperature Nursing Dx. Nursing assessment 4. Teaching parents regarding temp & environment Extra fluids administered with temp elevation.clothing Administer extra fluids Appropriate clothing provided.No. .

Nursing assessment 5.S. Expected outcome Planning Nursing Interventions Implementations Assessed the level of parental anxiety evaluation Interrupted family processes R/T the child’s life threatening Family will receive adequate support To assess the level of parental anxiety Parents could ventilate their anxiety To clarify the doubts of the parents Clarified the doubts of the parents To involve the parents in the care of the child Involved the parents in the care of the child To teach the parents the importance of adherence to the treatment regimen Taught the parents the importance of adherence to the treatment regimen . Parental anxiety Nursing Dx.No.