ANGELICA M.

REVIL
BSN 202

THE MCHN NURSING CARE PLAN

Family 2
Dianne is a gentle and loving 5-years-old. She is bubbly and loved by all. However, little by little upon the assessment from
head-to-toe, I recognized some early manifestations of Down syndrome, such as her flattened physical appearance, ears are also small and
dysplastic, her small mouth and nose, the wide gap between her first and second toes, and her protruding tongue. With the history of Down
Syndrome, Dianne pediatrician educated her parents thoroughly on what to expect on a child with Down syndrome and how they could make
Dianne’s life free from suffering despite her condition. While having a conversation with the parents I also observed that Dianne was having a hard
time bringing food to her mouth and because of that, I asked her parents again of what other problems they encountered of having a Down Syndrome child. Mrs.
Torres told me that, they were having difficulties on teaching Dianne because also of her cognitive impairment cause by the disorder. Mrs. Torres said “kalisod
ma’am, kailangan gajud ibanan sa cr kay di man mahibayo mam magpatay or mag flush maglisod pag cope-up, kailangan ilisan nimo kay di makabayo, pati sa
pagligo ma’am. Gusto tana namo makabayo ba and ma guide kami unsaon namo since nagdako sab raba ang bata at least jauy man lamang intervention amo
mahibal an kung unsaon namo ini sija pagtudlo or alternatives na himuon para mugaan gaan ang problima and mag improve sab sija” The patient’s vital signs are as
follows: : T: 36.5, P: 84, R: 18, BP: 120/90.

MATERNAL Nursing Care Plan – DOWN SYNDROME CHILD

TORRES FAMILY

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Self-care deficit: bathing After 1hr and 20 During 1hour and 20 After 1hour and 20 minutes of nursing
- “kalisod ma’am, and hygiene, dressing, minutes of nursing minutes of nursing intervention the nurse established rapport to
kailangan gajud intervention the intervention the nurse the family and the patient with her family
ibanan sa cr kay di feeding, toileting related
patient and the family established rapport to the can:
man mahibayo mam to cognitive impairment as
magpatay or mag will be able to: family and to the patient:
flush maglisod pag evidenced by bringing food “Goal Met”
cope-up, kailangan to her mouth and “kalisod -Verbalize at least 2-3 COLLABORATIVE: SHORT TERM:
ilisan nimo kay di
ma’am, kailangan gajud ibanan knowledge of health care
makabayo, pati sa sa cr kay di man mahibayo mam needs by verbalization of Assessed knowledge of -Verbalized at least 2-3 knowledge of health care
pagligo ma’am. magpatay or mag flush maglisod correct answers , Identify needs by verbalization of correct answers ,
Gusto tana namo
pag cope-up, kailangan ilisan at least 2-3 personnel Down Syndrome and its Identified at least 2-3 personnel and community
makabayo ba and
ma guide kami nimo kay di makabayo, pati sa
and community complications resources that can provide assistance and

unsaon namo since resources that can Assessed readiness to learn. performed at least 2-4 self-care activities within
pagligo ma’am. Gusto tana
nagdako sab raba provide assistance and -Implement teaching plan, level of own ability with 100% accuracy.
namo makabayo ba and ma
ang bata at least perform at least 2-4 self- which should include:
jauy man lamang guide kami unsaon namo since
care activities within level  The meaning of Down LONG TERM:
intervention amo nagdako sab raba ang bata at
of own ability with 100% Syndrome -Demonstrate at least 90% improvements and
mahibal an kung
least jauy man lamang accuracy. changes upon visit for reevaluation after 1 and half
unsaon namo ini sija  Explanation of risk
pagtudlo or intervention amo mahibal an factors which will month from the intervention
alternatives na kung unsaon namo ini sija aggravate Down
- The patient can do feeding, bathing, toileting, and
himuon para Syndrome
pagtudlo or alternatives na dressing with 100% accuracy
mugaan gaan ang Assisted the patient/family
problima and mag himuon para mugaan gaan ang
in identifying family strengths
improve sab sija” As problima and mag improve sab and resources.
verbalized by Mrs. sija” As verbalized by Mrs. Determine age and
Macaldo
Macaldo developmental issues affecting
- ability of individual to
participate in own care

Objective: Noted concomitant

medical problems or existing
-Early
conditions that may be
manifestations of factors for care (e.g, recent
trauma or surgery, heart
Down syndrome,
disease, renal failure,
such as her spinal cord injury, cerebral
vascular accident, multiple
flattened physical
sclerosis, malnutrition,
appearance, ears pain, Alzheimer disease)

are also small and Collaborated in

treatment of underlying
dysplastic, her
conditions to enhance
small mouth and client’s capabilities,
maximize rehabilitation
nose, the wide potential.
gap between her
Developed plan of care
first and second appropriate to individual
situation, scheduling
toes, and her activities to conform to
protruding tongue client’s usual or desired
schedule.
-Dianne was having
Promoted
a hard time bringing
client’s/significant other’s
food to her mouth (S/O’s) participation in
-History of Down problem identification and
desired goals and decision-
Syndrome
making. Enhances
-V/S taken as commitment to plan,
optimizing outcomes, and
follows:
supporting recovery and/or
T: 36.5 health promotion

P: 84 Practiced and promoted

short-term goal setting and
R: 18 achievement to recognize
that today’s success is as
BP: 120/90
important as any long-term
goal, accepting ability to do
one thing at a time and
conceptualization of self-
care in a broader sense.

Collaborated with
rehabilitation professionals
to identify and obtain
assistive devices, mobility
aids, and home modification,
as necessary(e.g., adequate
lighting, visual aids;
bedside commode; raised
toilet seat and grab bars
for bathroom; modified
clothing; modified eating
utensils) to enhance client’s
capabilities and promote
independence

Anticipated the needs and

begin with familiar, easily
accomplished tasks.

Instructed in or reviewed
appropriate skills necessary
for self care using terms
understandable to client (e.g,
child, adult, cognitively
impaired person) and with
sensitivity to
developmental needs for
practice, repetition, or
reluctance.

FEEDING DEFICIT:

Assisted client to handle

utensils or in guiding
utensils to mouth. May
require specialized
equipment (e.g, rocker
knife, plate guard, built-up
handles) to increase
independence or assistance
with movement of arms
and hands.

Reinforced the

importance of

adhering to

treatment regimen

and keeping follow

Advised to take
medication as prescribed by
the Doctor

BATHING DEFICIT:

Assisted client in and out

of shower or tub as
indicated. Bathe or assist
client bathing, providing for
any or all hygiene needs
indicated. Type (e.g, bed
bath towel bath, tub bath,
shower) and purpose (e.g,
cleansing, removing odor,
or simply soothing
agitation) of bath are
determined by individual
need

Asked client/SO for

input on bathing habits or
cultural bathing preferences.
Creates opportunities for
client to (1) kepp long-
standing routines (e.g.,
bathing at bedtimeto
improve sleep) and (2)
exercise control over
situation. This enhances
self-esteem, while
respecting personal and
cultural preferences.

Provided privacy and

equipement within easy
reach during presonal care
activities

Advised See a doctor if

necessary or if the condition
might worsen or if necessary

DRESSING DEFICIT:

Assisted client in
choosing clothing or lay out
clothing as indicated.
Taught client to dress
affected side first, then
unaffected side(when client
has paralysis or injury to one
side of the body)
Ascertained that
appropriate clothing was
available. Clothing may
need to be modified for
client’s particular medical
condition or physical
limitations.
TOILETING DEFICIT:
Provided mobility
assistance to bathroom or
commode or place on
bedpan or offer urinal, as
indicated.
Observed for behaviors
such as pacing, fidgeting, or
holding crotch that may be
indicative of need for
prompt toileting.
Assisted with
manipulation of clothing, if
needed, to decrease
incidence of functional
incontinence caused by
difficulty removing
clothing/underwear.
Kept toilet paper or wipes
and hand washing items
within client’s easy reach.
MCHN NCP 2

MATERNAL Nursing Care Plan – INSUFFICIENT BREASTMILK PRODUCTION

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE: Insufficient breast milk related to After 48 of nursing During 48 minutes of After 1 hour and 25 minutes of nursing
inappropriate breastfeeding style intervention the nurse nursing intervention: intervention the nurse established rapport to
“I think I don’t
produce enough milk and poor sucking of baby will establish rapport Independent: the Mother and was:
for my baby,” as
verbalized by the to the mother will be Encourage mother to breastfeed Short term:
as soon as possible.
mother able to: “Goal met”
Advise mother to Breast-feed After 48 hours of nursing interventions, goal met.
 losing the feeling
of fullness in the often
> Mother will be able to Mother was able to identify ways and increase milk
breasts
increase milk production Advise mother to not skip production, baby was able to gain weight
OBJECTIVES: breast-feeding sessions.
and identify ways to approximately 18-30 grams/day; feel content after
 milk stops leaking produce more milk Teach mother to be alert to each feeding; has six or more wet diapers in 24
from the nipples feeding problems hours; with pale, diluted urine and has three to
> baby will be able to
 baby has less than gain weight, feel content Advise mother to avoid alcohol eight bowel movements in 24 hours
6 wet diapers in 24 after feeding; have and nicotine
hours; with
normal urine output and If the baby is sleepy, try
yellowish,
bowel movements. switching sides frequently,
undiluted urine.
alternating positions, or even
- undressing him to keep him
 Baby weight loss awake and interested

 Baby bowel Promote sleep and rest as well

movement less as a healthy diet
than 3 in 24 hours

 Little amount of
breast milk

Absence of breast Collaborative:

engorgement Check for mother’s thyroid

levels

BARA
BARA