NURSING CARE PLAN

CARE OF THE MOTHER, CHILD AT RISK

OR WITH PROBLEMS (ACUTE AND CHRONIC)
NCM 109

ZAMORA, ELIZABETH O.
NR 23

PROF. MARISSA M. GOCO

April 9, 2021

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 1. HIRSCHSPRUNG'S DISEASE

Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

Subjective data Constipation Hirschsprung's After 7 days of  Promote comfort  Observe for signs of After 7 days of
pain, such as crying,
“Parang related to disease is a nursing  Maintain fluid pulse and respiration rate nursing
kinakabag po decreased bowel condition that intervention, balance increases, restlessness, intervention,
 Provide oral and guarding of the abdomen,
yung anak ko. motility. affects the large patient will no or drawing up the legs; patient is no
nasal care administer analgesics as
Tapos po, hindi intestine (colon) longer experience  Administer longer
ordered; additional
po siya mapakali, and causes constipation and medications nursing measures that experiencing
iyak lang po siya problems with diarrhea. The can be used are changing constipation and
appropriately as the child’s position,
ng iyak”, as passing stool. The patient will be prescribed by the holding the child when diarrhea. The
verbalized by the condition is also comfortable pediatrician. possible, stroking, patient is also
cuddling, and engaging
patient’s parent. present at birth and will have  Provide patient comfortable and
in age-appropriate
and parent activities.
(congenital) as a fluid balance. has fluid balance.
education  Accurate intake and
“Nagtatae po at result of missing regarding output determinations
and reporting the
nagsusuka rin po nerve cells in the lifestyle character, amount, and
ang anak ko”, as muscles of the restrictions and consistency of stools
verbalized by baby's colon. prevention of help determine when the
child may have oral
patient’s parent. complications feedings; to monitor fluid
loss, record and report
A newborn who
the drainage from the NG
has tube every 8 hours; and
immediately report any
Objective data Hirschsprung's
unusual drainage, such as
The patient has disease usually bright-red bleeding.
 Perform good mouth care
swollen belly. can't have a bowel
at least every 4 hours; at
movement in the the same time, gently
clean the nares to relieve

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 days after birth. In any irritation from the
NG tube.
mild cases, the  Exercise restrictions may
condition might be necessary depending
on the condition and
not be detected severity. Reduce the risk
until later in of infection with good
dental care and hygiene
childhood. practices. Encourage
Uncommonly, healthy diet and
hydration.
Hirschsprung's
disease is first
diagnosed in
adults.

2. INTUSSUSCEPTION
Assessment Diagnosis Inference Planning Intervention Rationale Evaluation
Subjective data Deficient fluid Intussusception is After 7 days of  Monitor vital  Vital sign changes After 7 days of
such as hypotension,
“Nagsusuka at
volume related to a serious nursing signs as nursing
tachycardia and
nagtatae po ang excessive losses condition in intervention, frequently as increased temperature intervention,
possible. reveals hypovolemia.
anak ko”, as through normal which part of the patient will no patient is no
 Assess fluid  Measurement of fluid
verbalized by the routes as intestine slides longer experience intake and intake and output is an
longer
patient’s parent. evidenced by into an adjacent vomiting and output. important indicator of experiencing
vomiting and part of the diarrhea, and  Monitor child’s fluid status. vomiting and
 Initially, a child with
“Yung tae niya po diarrhea. intestine. This child will be able characteristic of intussusception may
diarrhea, and
ay malabot, para telescoping action to tolerate age- stool pass a normal stool, child had been
pong jelly ace and often blocks food appropriate foods (consistency and but later on, a mucus, able to tolerate
color). blood-filled or jelly-
texture po at or fluid from and fluids without age-appropriate
 Administer IV like stool is observed.
matamlay din po passing through. vomiting or fluids or other  Post-operatively, foods and fluids

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siya nitong mga Intussusception recurrence of medication as intravenous fluids are without vomiting
continued to re-
nagdaang araw”, also cuts off the symptoms and ordered. established electrolyte
or recurrence of
as verbalized by blood supply to will be free from  Instruct parents imbalance and to symptoms and
that they may promote adequate
patient’s parent. the part of the fluid and free from fluid
offer clear fluid intake.
intestine that's electrolyte liquids then  A clear liquid diet,
and electrolyte
affected. This can imbalances. gradually then progressing to imbalances.
Objective data lead to a tear in advanced diet as soft diet is given until
normal bowel function
The patient has the bowel tolerated. is established.
lump on her (perforation),
abdomen. infection and
death of bowel
tissue.

Intussusception is
the most common
cause of intestinal
obstruction in
children younger
than 3 years old.
The cause of most
cases of
intussusception in
children is
unknown. Though
intussusception is
rare in adults,
most cases of

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adult
intussusception
are the result of
an underlying
medical
condition, such as
a tumor.

In children, the
intestines can
usually be pushed
back into position
with a minor
procedure. In
adults, surgery is
often required to
correct the
problem.

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