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. PNEUMONIA

Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

Subjective data Activity An atrial septal After 7 days of  Assess and  Patient may have After 7 days of
tachycardia with low
“Wala pong Intolerance defect (ASD) is a nursing monitor vital blood pressure. Monitor nursing
ganang kumain related to hole in the wall intervention, signs. for changes from intervention, the
 Position patient baseline.
ang anak ko at generalized (septum) between patient will have  An upright position patient has
for comfort in makes breathing easier as
minsan naman po weakness and the two upper optimal activity upright or semi- optimal activity
it allows the lungs to
ay sobrang hirap imbalance chambers of your tolerance. Fowler’s expand more fully and tolerance, normal
niya pong between oxygen heart (atria). The decreases stress on the skin color, and
position. heart. Patients may prefer
pakainin at kaunti supply and condition is  Auscultate heart to sit with legs pulled up appetite in eating.
lamang po ang demand as present at birth and lungs for to the chest, or young
children may prefer to
kinakain”, as evidenced by (congenital). abnormal play in the squatting
sounds. position.
verbalized by the needs to rest after
 Assess skin for  Listen for murmurs or
patient’s parent. short period of Small defects cyanosis or pale gallops to help determine
location and severity of
play might be found by color condition. Abnormal
“Kapag naglalaro chance and never  Administer lungs sounds may
po siya ay mabilis cause a problem. medications indicate pulmonary
edema related to heart
po siyang hingalin Some small atrial appropriately as failure.
at may septal defects prescribed by the  Bluish or pale gray color
pediatrician. indicates lack of
pagkakataon pong close during oxygenation and may be
 Cluster care and present in fingers and
nahimatay siya infancy or early provide rest around the mouth at first.
kakatakbo”, as childhood. periods.  Medications may be
given depending on the
verbalized by  Provide patient particular defect, such as
patient’s parent. The hole and parent prostaglandins to keep
education the PDA open.

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 increases the regarding Prostaglandins are used
to keep a PDA
amount of blood lifestyle patent/open until surgery
Objective data that flows through restrictions and occurs to close the PDA.
prevention of Prostaglandin inhibitors
The patient is the lungs. A large, (such as NSAIDS) can
complications also be used to close the
experiencing long-standing
PDA if surgery is not
tachypnea, she atrial septal defect needed.
has pale gray skin can damage your  Decrease the demand and
stress on the heart and
color, and her heart and lungs. lungs.
hands and feet are Surgery or device  Exercise restrictions may
be necessary depending
swelling. closure might be on the condition and
necessary to severity. Reduce the risk
of infection with good
repair atrial septal dental care and hygiene
practices. Encourage
defects to prevent
healthy diet and
complications. hydration.

2. VENTRICULAR SEPTAL DEFECT

Assessment Diagnosis Inference Planning Intervention Rationale Evaluation
Subjective data Decreased A ventricular After 7 days of  Position child in  Upright position is After 7 days of
recommended to
“Madals pong Cardiac Output septal defect nursing semi-Fowler’s nursing
reduce preload and
hingaling ang related to (VSD), a hole in intervention, position. ventricular filling intervention, the
 Note skin color, when fluid overload is
anak ko at structural factors the heart, is a patient will patient
temperature, and the cause; Facilitates
sobrang bilis po of ventricular common heart demonstrate moisture. lung expansion.
demonstrated
mapagod habang heart defect defect that's adequate cardiac  Assess heart rate  Cold, clammy, and adequate cardiac
naglalaro at kahit possible present at birth output as and blood pale skin is secondary output as
to a compensatory
habang kumakain evidenced by (congenital). The evidenced by an pressure. increase in
evidenced by an
lamang”, as dyspnea. hole (defect) ability to tolerate  Inspect fluid sympathetic nervous ability to tolerate
balance and

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verbalized by the occurs in the wall activity without weight gain. system stimulation activity without
and low cardiac output
patient’s parent. (septum) that symptoms of Weigh patient symptoms of
and oxygen
separates the dyspnea, syncope, regularly prior to desaturation. dyspnea, syncope,
breakfast.  Most patients have
“Hindi rin po siya heart's lower or chest pain. or chest pain, and
 Assess for compensatory
tumataba kahit chambers reports of fatigue tachycardia and
the patient gained
tama naman po (ventricles) and and reduced significantly low the appropriate
ang pagkain at allows blood to activity blood pressure in weight.
response to reduced
pag inom niya ng pass from the left tolerance. cardiac output.
gatas at may to the right side of  Administer  Compromised
pagakakataon din the heart. The medications regulatory
appropriately as mechanisms may
pong pag umiiyak oxygen-rich blood
prescribed by the result in fluid and
po siya ng sobra then gets pumped pediatrician. sodium retention;
ay nawawalan po back to the lungs  Provide adequate Weight is an indicator
of fluid balance.
siya ng malay”, as instead of out to rest periods.  Fatigue and exertional
verbalized by the body, causing dyspnea are common
patient’s parent. the heart to work problems with low
cardiac output states.
harder. Close monitoring of
the patient’s response
A small serves as a guide for
optimal progression of
ventricular septal activity.
defect may cause  Maintain open PDA
no problems, and when needed for
blood flow. Increases
many small VSDs contractility of the
close on their heart and force of
own. Medium or contraction. Decreases
edema formation and
larger VSDs may diminish afterload.
need surgical  Rest decreases

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 repair early in life metabolic rate,
decreasing myocardial
to prevent and oxygen demand.
complications.
PNEUMONIA
Assessment Diagnosis Inference Planning Intervention Rationale Evaluation
Subjective data Ineffective Pneumonia is an After 7 days of  Observe for  Unusual breathing After 7 days of
patterns may imply an
“Ang ubo po ng Breathing Pattern infection in the nursing breathing underlying disease nursing
anak ko ay may related to pain as lungs. It can be intervention, patterns. process or dysfunction. intervention, the
 Auscultate Cheyne-Stokes’s
plema at sa evidenced by mild or serious. patient will respiration signifies patient maintained
breath sounds at bilateral dysfunction in
tuwing umuubo purulent sputum Pneumonia is maintain an least every four an effective
the deep cerebral or
po siya palagi generally more effective (4) hours. diencephalon related breathing pattern,
niya pong common in breathing pattern, with brain injury or as evidenced by
 Place patient metabolic abnormalities.
sinasabi sakin na children younger as evidenced by with proper body Apneusis and ataxic relaxed breathing
nasakit po ang than 5 years old. relaxed breathing alignment for breathing are related with at normal rate, no
failure of the respiratory
dibdib niya”, as at normal rate. maximum sputum, and
centers in the pons and
breathing medulla.
verbalized by the Pneumonia is didn’t
pattern.  This is to detect
patient’s parent. most often caused  Maintain a clear decreased or experienced
by bacteria or airway by adventitious breath vomiting.
“Nagsusuka rin viruses. Some of sounds.
encouraging
 A sitting position
po siya, nahihilo these bacteria and patient to permits maximum
at nahihirapan viruses can be mobilize own lung excursion and
huminga”, as spread by direct secretions with chest expansion.
successful  This facilitates
verbalized by contact with a adequate clearance of
coughing.
patient’s parent. person who is  Encourage secretions.
already infected  Extra activity can
frequent rest worsen shortness of
with them. periods and breath. Ensure the
teach patient to patient rests between

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 pace activity. strenuous activities.
 This prevents
 Encourage small
crowding of the
frequent meals. diaphragm.

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