Nursing Related Learning Experience Manual
NURSING CARE PLAN
Name of Patient Kaylee
Address General Santos City
ASSESSMENT
PATTERN
Subjective Cues:
* Returns to the
operating room 4
days post-op for
cauterization of post
tonsillectomy bleed
Objective Cues
* Physical exam
reveals pale skin
tones, tacky mucous
membranes, with no
active tonsillectomy
bleeding.
*Tylenol with
Codeine 3/4 teaspoon
is ordered q4h prn
pain
* Kaylee still refused
to drink anything at
College of Health Sciences Department of Nursing
Rm/Bed No. 2C 202 Age 18 Chief Complaints Tonsillectomy
Months/old
Admission Date 7 / 20 / 2020 Sex - Diagnosis Impaired comfort r/t separation anxiety
HEALTH NURSING DIAGNOSIS DESIRED OUTCOME INTERVENTION EVALUATION REMARKS
C Note: Use P-E-S format General Objective Independent Goal was met,
O client’s
Impaired comfort r/t
G Within 24 hours of *Determine the type of discomfort client is perception of
separation anxiety as
N nursing intervention, experiencing, such as physical pain, feeling of discomfort
manifested by missing her
I client’s subjective discontent, lack of ease with self, environment, decreases and
twin brother so much that it
T perception of altered or socio-cultural settings, or inability to rise diminished or
was affecting everything
I comfort/pain will be above one’s problems or pain (lack of absence of
she could see or do and
V decreased; patient will be transcendence). nonverbal
Continuing to refuse PO
E able to verbalize comfort; indicators.
fluids even with regular
there will be diminish or Rationale: This will help the client to identify
administration of analgesic
P absent nonverbal focus of discomfort (e.g., physical, emotional,
E indicators social).
R
Background Knowledge
C Specific Objective *Ascertain what has been tried or is required
E for comfort or rest (e.g., head of bed up/down,
Impaired Comfort is
P *Patient will engage in music on/off, certain person or thing).
defined as “perceived lack
T behaviors or lifestyle
of feeling of comfort, relief
U changes to increase level Rationale: This will help the nurses to identify
and transcendence in
A of ease. some factors that affect the client’s comfort
physical, psychospiritual,
L and will help to the client to cooperate in the
environmental and social
*Patient will treatment regimen.
dimensions.”In relation to
P verbalize/non-verbalize
the problem, there is a
A sense of comfort or *Suggest parent/siblings be present during
presence of discomfort felt
T contentment procedure
by the client and also
T
there’s a lot of factors
E *Patient will participate Rationale: To comfort child and will boost the
resulting to discomfort such
R in desirable and realistic clients self esteem to follow different
as pain because the client
N health-seeking behaviors. treatments.
recently have
tonsillectomy, other is
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 Nursing Related Learning Experience Manual

all separation anxiety because *Provide age-appropriate comfort measures

of her twin brother got (e.g., back rub, change of position and
* Nurse realized that separated due to cuddling)
Kaylee was missing hospitalization. Nurses
her twin brother so need would give immediate Rationale: To provide nonpharmacological
much that it was intervention to alleviate the pain management and promote relaxation
affecting everything client’s responses towards towards the client.
she could see or do treatment regimen.
*Use age-appropriate distraction with music,
* Continuing to refuse Ref NANDA 13TH ED reading, chatting or texting with family and
PO fluids even with 2020 friends, watching TV or movies, or playing
regular administration video or computer games
of analgesic
Rationale: To limit dwelling on and transcend
* Kaylee’s behavior unpleasant sensations and situations and to be
consisted of cooperative in achieving towards goal
continually holding a outcomes.
blue blanket and
watching the door, *Encourage age-appropriate diversional
crying “Bubby … activities (e.g., TV/ radio, computer games,
Bubby” repeatedly play time, socialization/outings with others).

Rationale: This will helps the clients to boost

morale to follow health practitioner towards
treatment regimen.

*Allow frequent visitations during

hospitalization especially the parents/siblings.

Rationale: Create a supportive and therapeutic

environment incorporating client’s cultural and
age or development.

Dependent

*Refer the client to the physician who

specialize Otorhinolaryngology.

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

Rationale: This will evaluate further the recent

surgery for any complication and treatment
regarding the surgery.

*Educate the parent of client for medications

needed to take.

Rationale: This will provide independent

administrating of medications towards the
client.

ASSESSMENT HEALTH NURSING DIAGNOSIS DESIRED OUTCOME INTERVENTION EVALUATION REMARKS

PATTERN

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

Read the following case study. Then work through the steps of analysing the case study data.

First identify abnormal data and strengths in subjective and objective findings;
Strengths:

 Kaylee, an 18-month-old, returns to the operating room 4 days post-op for cauterization of post tonsillectomy bleed.
 Vital signs upon returning to the pediatric floor after surgery are weight 11.83 kg, BP 109/71, apical heart rate 144, respiratory rate 28, temperature 99.4F axillary, and pulse ox 96% room
air
 Kaylee began to drink normally during a “pretend picnic” on the floor with her brother
 Tylenol with Codeine 3/4 teaspoon is ordered q4h prn pain.

Abnormalities:

 Initial lab results indicate moderate dehydration and moderate anemia.

 Physical exam reveals pale skin tones, tacky mucous membranes, with no active tonsillectomy bleeding.
 Kaylee remains on the floor for 4 subsequent days—continuing to refuse PO fluids even with regular administration of analgesic
 Two days after admission, a trial of locking IV fluids is initiated with plan to discharge if Kaylee tolerates PO fluids through supper. If unable to tolerate PO, restart IV fluids at 50 cc/hour.
This trial fails this day and the following day has a total PO intake of sips and urine output of 141 cc for the 24-hour period.
 A repeat IV bolus is given and the same course of action is taken the next day. Again, this trial fails and IV fluids are re-initiated
 Several days after returning to the OR for cauterization, Kaylee still refused to drink anything at all
 Kaylee’s behavior consisted of continually holding a blue blanket and watching the door, crying “Bubby … Bubby” repeatedly
 After having much interaction with Kaylee and her family, and assessing the situation, the nurse realized that Kaylee was missing her twin brother so much that it was affecting everything
she could see or do.
College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY
 Nursing Related Learning Experience Manual

Assemble cue clusters;

Subjective:

 Returns to the operating room 4 days post-op for cauterization of post tonsillectomy bleed.
Objective:

 Initial lab results indicate moderate dehydration and moderate anemia.

 Physical exam reveals pale skin tones, tacky mucous membranes, with no active tonsillectomy bleeding.
 Kaylee remains on the floor for 4 subsequent days—continuing to refuse PO fluids even with regular administration of analgesic
 Two days after admission, a trial of locking IV fluids is initiated with plan to discharge if Kaylee tolerates PO fluids through supper. If unable to tolerate PO, restart IV fluids at 50cc/hour.
This trial fails this day and the following day has a total PO intake of sips and urine output of 141 cc for the 24-hour period.
 A repeat IV bolus is given and the same course of action is taken the next day. Again, this trial fails and IV fluids are re-initiated
 Several days after returning to the OR for cauterization, Kaylee still refused to drink anything at all
 Kaylee’s behavior consisted of continually holding a blue blanket and watching the door, crying “Bubby … Bubby” repeatedly
 After having much interaction with Kaylee and her family, and assessing the situation, the nurse realized that Kaylee was missing her twin brother so much that it was affecting everything
she could see or do.
 Kaylee, an 18-month-old, returns to the operating room 4 days post-op for cauterization of post tonsillectomy bleed.
 Vital signs upon returning to the pediatric floor after surgery are weight 11.83 kg, BP 109/71, apical heart rate 144, respiratory rate 28, temperature 99.4F axillary, and pulse ox 96% room
air
 Kaylee began to drink normally during a “pretend picnic” on the floor with her brother
 Tylenol with Codeine 3/4 teaspoon is ordered q4h prn pain.

Draw inferences;

 Impaired comfort
 Risk for deficit fluid volume
 Ineffective coping
Make possible nursing diagnoses;

 Impaired comfort r/t separation anxiety

 Risk for deficit fluid volume r/t moderate dehydration
 Ineffective coping r/t separation anxiety

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

Identify defining characteristics;

 Impaired comfort: Missing her twin brother so much that it was affecting everything she could see or do and Kaylee’s behavior consisted of continually holding a blue blanket and
watching the door, crying “Bubby … Bubby” repeatedly and refuses any treatment regimen
 Risk for deficit fluid volume: Initial lab results indicate moderate dehydration and moderate anemia and Several days after returning to the OR for cauterization, Kaylee still refused to
drink anything at all
 Ineffective coping : Missing her twin brother so much that it was affecting everything she could see or do

Confirm or rule out the diagnoses; and

 NCP
Document your conclusions.

 NCP

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY