1.

PHARYNGITIS
- is inflammation of the pharynx, which is in the back of the throat. It is most often referred
to simply as “sore throat.” It can also cause scratchiness in the throat and difficulty
swallowing.
NURSING DIAGNOSES:
○ Ineffective breathing pattern related to the inflammatory process in the
respiratory tract.
■ Evaluation: The patient will expectorate sputum effectively.
○ Ineffective airway clearance related to mechanical obstruction of the airway
secretions and increased production of secretions.
■ Evaluation: The patient will express feelings of comfort in maintaining air
exchange.
○ Anxiety-related to the disease experienced by the child.
■ Evaluation: The patient will remain afebrile.

2. TONSILLITIS
- is inflammation of the tonsils, two oval-shaped pads of tissue at the back of the throat — one
tonsil on each side. Signs and symptoms of tonsillitis include swollen tonsils, sore throat,
difficulty swallowing, and tender lymph nodes on the sides of the neck.
- NURSING DIAGNOSES:
○ Ineffective Airway Clearance related to thick secretions characterized by
difficulty in breathing.
■ Evaluation: Child will maintain a patent airway as demonstrated by normal
respiratory rate and rhythm and clear breath sounds.
○ Acute Pain
■ Evaluation: Child will state level of pain is decreased and will appear more
relaxed/comfortable.
○ Deficient Knowledge
■ Evaluation: Parents will gain the knowledge to care for the postoperative
child safely at home.
3. EPISTAXIS
 - acute hemorrhage from the nostril, nasal cavity, or nasopharynx. It is a frequent emergency
department (ED) complaint and often causes significant anxiety in patients and clinicians.
- NURSING DIAGNOSES:
○ Risk for Bleeding
■ Evaluation: No bleeding, vital signs within normal limits, no anemis.
○ Ineffective airway clearance
■ Evaluation: Frequency of normal breathing, no additional breath sounds, do not
use additional respiratory muscles, dyspnoea and cyanosis does not occur.
○ Acute pain
■ Evaluation: Clients express the pain diminished or disappeared; clients do not
grimace in pain

4. SINUSITIS
- Is inflammation or swelling of the tissue lining the sinuses
- NURSING DIAGNOSES
● Acute pain
○ Evaluation: Clients express the pain diminished or disappeared; Clients do not
grimace in pain
● Anxiety related to lack of client knowledge about diseases
○ Evaluation: Anxiety is reduced / lost
● Ineffective Airway Clearance related to the obstruction (nasal secret buildup)
secondary to inflammation of the sinuses
○ Evaluation: Effective airway, after a secret (seous, purulent) issued

5. EPIGLOTTITIS
- It is an inflammation and swelling of the epiglottis. Usually caused by a bacterial
infection, it can cause pain when swallowing, severe sore throat and difficulty breathing.
NURSING DIAGNOSES:
 ● Ineffective Airway Clearance related Obstruction associated with edema and
excessive mucus production in the upper airways
○ Evaluation: The child’s airway will remain clear.
● Hyperthermia
○ Evaluation: Child’s body temperature will maintain between 36.4° C- 37.5°C.
● Anxiety
○ Evaluation:
■ Parents will verbalize decreased anxiety.
■ Child will appear calm without agitation, crying or irritability.

5. ASPIRATION

- is breathing in a foreign object such as foods or liquids into the trachea and lungs and happens
when protective reflexes are reduced or jeopardized.
● Acute pain
○ Evaluation: Clients express the pain diminished or disappeared; Clients do not
grimace in pain
● Anxiety related to lack of client knowledge about diseases
○ Evaluation: Anxiety is reduced / lost
● Ineffective Airway Clearance related to the obstruction (nasal secret buildup)
secondary to inflammation of the sinuses
○ Evaluation: Effective airway, after a secret (seous, purulent) issued

7. FLU

- is a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and
sometimes the lungs. It can cause mild to severe illness, and at times can lead to death. The
best way to prevent flu is by getting a flu vaccine each year.
- NURSING DIAGNOSES
 ○ Ineffective Airway Clearance related to tracheobronchial and nasal secretions.
■ Evaluation: Patient will achieve and maintain a patent airway.
○ Ineffective Breathing Pattern related to inflammation from viral infection.
■ Evaluation: Patient will achieve and maintain normal respiratory pattern
and rate, with no adventitious breath sounds to auscultation.
○ Hyperthermia related to exposure to infection.
■ Evaluation: Patient will achieve and maintain a normal temperature.

8. PNEUMONIA

- is an infection that affects one or both lungs. It causes the air sacs, or alveoli, of the lungs to fill
up with fluid or pus. Bacteria, viruses, or fungi may cause pneumonia.
○ Ineffective Airway Clearance
■ Evaluation:
1. Patient will identify/demonstrate behaviors to achieve airway
clearance.
2. Patient will display/maintain patent airway with breath sounds
clearing; absence of dyspnea, cyanosis, as evidenced by keeping a
patent airway and effectively clearing secretions.
○ Impaired Gas Exchange
■ Evaluation:
1. Patient will demonstrate improved ventilation and oxygenation of
tissues by ABGs within patient’s acceptable range and absence of
symptoms of respiratory distress.
2. Patient will maintain optimal gas exchange.
3. Patient will participate in actions to maximize oxygenation.
○ Ineffective Breathing Pattern
■ Evaluation:
 1. Patient maintains an effective breathing pattern, as evidenced by
relaxed breathing at normal rate and depth and absence of
dyspnea.
2. Patient’s respiratory rate remains within established limits.

9. CYSTIC FIBROSIS

- is an inherited disorder that causes severe damage to the lungs, digestive system and other
organs in the body.
- NURSING DIAGNOSES
○ Impaired Gas Exchange
■ Evaluation: Client will maintain optimal gas exchange as evidenced by
oxygen saturation of 90% or greater, arterial blood gasses (ABGs) within
the client’s usual range, relaxed breathing, baseline heart rate, alert
response mentation and no further deterioration in the level of
consciousness.
○ Ineffective Airway Clearance
■ Evaluation:
1. Client will be proficient in using effective airway clearance therapies
to clear secretions on a daily basis, as evidenced by decreased
work of breathing and improved pulmonary function.
2. Client will maintain clear, open airway as evidenced by normal
breath sounds, normal rate and depth of respirations, and an
airway free of secretions, with an effective cough.
○ Imbalanced Nutrition: Less Than Body Requirements
■ Evaluation: Client will maintain adequate nutritional status or demonstrate
weight gain on a trajectory to adequate nutritional status.
■ Client will be free of signs/symptoms of malabsorption.
10. SEPTAL DEFECT

- is a birth defect of the heart in which there is a hole in the wall (septum) that divides the upper
chambers (atria) of the heart. A hole can vary in size and may close on its own or may require
surgery. An atrial septal defect is one type of congenital heart defect.
- NURSING DIAGNOSES
○ Decreased Cardiac Output
■ Child will demonstrates adequate cardiac output as evidenced by blood
pressure and pulse rate and rhythm within normal parameters for patient;
strong peripheral pulses; and an ability to tolerate activity without
symptoms of dyspnea, syncope, or chest pain.
○ Activity Intolerance
■ Child will tolerate increased activity
○ Compromised Family Coping
■ Family will cope more effectively.

11. PATENT DUCTUS ARTERIOSUS (PDA)

- is a persistent opening between the two major blood vessels leading from the heart. The
opening (ductus arteriosus) is a normal part of a baby's circulatory system in the womb that
usually closes shortly after birth.
- NURSING DIAGNOSES
○ Activity Intolerance related to imbalance between oxygen consumption of the
body and supply of oxygen to the cells.
■ Outcome Evaluation:
1. Reduced the increase in pulmonary vascular resistance.
2. Maintained adequate levels of activity.
 3. Provided support for growth and development.
4. Maintained appropriate weight and height development.
○ Anxiety related to hospital care or lack of support system.
■ Outcome Evaluation:
1. Reduced the increase in pulmonary vascular resistance.
2. Maintained adequate levels of activity.
3. Provided support for growth and development.
4. Maintained appropriate weight and height development.
○ Deficient knowledge related to the condition and treatment needs.
■ Outcome Evaluation:
1. Reduced the increase in pulmonary vascular resistance.
2. Maintained adequate levels of activity.
3. Provided support for growth and development.
4. Maintained appropriate weight and height development.

11. PULMONARY STENOSIS

- a narrowing of the pulmonary valve and main pulmonary artery

- NURSING DIAGNOSES
○ Decreased Cardiac Output
■ Child will demonstrates adequate cardiac output as evidenced by blood
pressure and pulse rate and rhythm within normal parameters for patient;
strong peripheral pulses; and an ability to tolerate activity without
symptoms of dyspnea, syncope, or chest pain.
○ Activity Intolerance
■ Child will tolerate increased activity
○ Compromised Family Coping
■ Family will cope more effectively.
13. COARCTATION OF THE AORTA

- is a birth defect in which a part of the aorta, the tube that carries oxygen-rich blood to the
body, is narrower than usual.
- NURSING DIAGNOSES
○ Decreased Cardiac Output
■ Child will demonstrates adequate cardiac output as evidenced by blood
pressure and pulse rate and rhythm within normal parameters for patient;
strong peripheral pulses; and an ability to tolerate activity without
symptoms of dyspnea, syncope, or chest pain.
○ Activity Intolerance
■ Child will tolerate increased activity
○ Compromised Family Coping
■ Family will cope more effectively.

14. TETRALOGY OF FALLOT

- is a birth defect that affects normal blood flow through the heart. It happens when a baby’s
heart does not form correctly as the baby grows and develops in the mother’s womb during
pregnancy
- NURSING DIAGNOSES
○ Decreased Cardiac Output
■ Child will demonstrates adequate cardiac output as evidenced by blood
pressure and pulse rate and rhythm within normal parameters for patient;
strong peripheral pulses; and an ability to tolerate activity without
symptoms of dyspnea, syncope, or chest pain.
 ○ Activity Intolerance
■ Child will tolerate increased activity
○ Compromised Family Coping
■ Family will cope more effectively.

15. AORTIC VALVE STENOSIS

- or aortic stenosis — occurs when the aortic valve narrows. The valve does not open fully,
which reduces or blocks blood flow from the heart into the main artery to the body (aorta) and
to the rest of the body.
- NURSING DIAGNOSES
○ Decreased Cardiac Output
■ Patient will demonstrate adequate cardiac output as evidenced by vital
signs within acceptable limits, dysrhythmias absent/controlled, and no
symptoms of failure (e.g., hemodynamic parameters within acceptable
limits, urinary output adequate).
■ Patient will report decreased episodes of dyspnea, angina.
■ Patient will participate in activities that reduce cardiac workload.
○ Activity Intolerance
■ Participate in desired activities; meet own self-care needs.
■ Achieve measurable increase in activity tolerance, evidenced by reduced
fatigue and weakness and by vital signs within acceptable limits during
activity.
○ Excess Fluid Volume
■ Demonstrate stabilized fluid volume with balanced intake and output,
breath sounds clear/clearing, vital signs within acceptable range, stable
weight, and absence of edema.
■ Verbalize understanding of individual dietary/fluid restrictions.
16. TRANSPORTATION OF GREAT ARTERIES (TGA)

- is a birth defect of the heart in which the two main arteries carrying blood out of the heart – the
main pulmonary artery and the aorta – are switched in position, or “transposed.”
- NURSING DIAGNOSES
○ Decreased Cardiac Output
■ Child will demonstrates adequate cardiac output as evidenced by blood
pressure and pulse rate and rhythm within normal parameters for patient;
strong peripheral pulses; and an ability to tolerate activity without
symptoms of dyspnea, syncope, or chest pain.
○ Activity Intolerance
■ Child will tolerate increased activity
○ Compromised Family Coping
■ Family will cope more effectively.

17. CONGESTIVE HEART FAILURE

- Heart failure happens when the heart cannot pump enough blood and oxygen to support other
organs in your body. Heart failure is a serious condition, but it does not mean that the heart
has stopped beating.
- NURSING DIAGNOSES
○ Decreased Cardiac Output
■ Patient will demonstrate adequate cardiac output as evidenced by vital
signs within acceptable limits, dysrhythmias absent/controlled, and no
symptoms of failure (e.g., hemodynamic parameters within acceptable
limits, urinary output adequate).
■ Patient will report decreased episodes of dyspnea, angina.
■ Patient will participate in activities that reduce cardiac workload.
○ Activity Intolerance
 ■ Participate in desired activities; meet own self-care needs.
■ Achieve measurable increase in activity tolerance, evidenced by reduced
fatigue and weakness and by vital signs within acceptable limits during
activity.
○ Excess Fluid Volume
■ Demonstrate stabilized fluid volume with balanced intake and output,
breath sounds clear/clearing, vital signs within acceptable range, stable
weight, and absence of edema.
■ Verbalize understanding of individual dietary/fluid restrictions

18. PERSISTENT PULMONARY HYPERTENSION OF THE NEWBORN (PPHN)

- is defined as the failure of the normal circulatory transition that occurs after birth. It is a
syndrome characterized by marked pulmonary hypertension that causes hypoxemia secondary
to right-to-left shunting of blood at the foramen ovale and ductus arteriosus.

19. RHEUMATIC FEVER (ACUTE RHEUMATIC FEVER)

- is a disease that can affect the heart, joints, brain, and skin. Rheumatic fever can develop if
strep throat and scarlet fever infections are not treated properly.
- NURSING DIAGNOSES
○ Acute pain related to joint pain when extremities are touched or moved.
■ Reducing pain.
■ Providing diversional activities and sensory stimulation.
■ Conserving energy.
■ Preventing injury.
○ Deficient diversional activity related to prescribed bed rest.
■ Reducing pain.
 ■ Providing diversional activities and sensory stimulation.
■ Conserving energy.
■ Preventing injury.
○ Activity Intolerance related to carditis or arthralgia.
■ Reducing pain.
■ Providing diversional activities and sensory stimulation.
■ Conserving energy.
■ Preventing injury.

20. KAWASAKI DISEASE (KD)

- also known as mucocutaneous lymph node syndrome and Kawasaki syndrome, is an acute
febrile illness of early childhood characterized by vasculitis of the medium-sized arteries.
- NURSING DIAGNOSES
○ Hyperthermia
■ Child will maintain a normal temperature.
○ Acute Pain
■ Child will experience less pain.
○ Impaired Skin Integrity
■ Child will manifest healing of peripheral erythema.

21. INFECTIVE ENDOCARDITIS (IE)

- is an infection of the endocardial surfaces of the heart—primarily of 1 or more heart valves, the
mural endocardium, or a septal defect.
- NURSING DIAGNOSES
○ Acute pain related to systemic effects of infection.
■ Reported pain gone / controlled.
 ■ Demonstrate the use of the skills of relaxation and diversion activities as
indicated for individual situation.
■ Identify methods that give disappearance.
● Risk for decreased cardiac output related to disorders of the heart valves and the
endothelium.
■ Nutritional status is maintained / repaired.
■ Achievement fixes weight according to age, gender.]=
■ Clients revealed increased appetite.
● Altered body temperature related to the infection process.
○ Inflammatory process has been lost.
○ Moist and dry skin.

22. HYPOSPADIAS

- is a birth defect in boys where the opening of the urethra is not located at the tip of the penis.
- NURSING DIAGNOSES
○ Acute Pain Related to Surgery
■ Evaluation: Child will experience decreased pain as evidenced by
infrequent crying episodes and exhibit normal sleeping pattern.
○ Impaired Urinary Elimination Related to Mechanical trauma from surgery
(urethroplasty)
■ Evaluation: Child will experience improved urinary elimination.
○ Anxiety related to self-concept
■ Evaluation: Parent will experience less anxiety.

23. URINARY INCONTINENCE (ENURESIS)

- is the loss of bladder control.

 - NURSING DIAGNOSES
○ Impaired urinary elimination
■ Evaluation: Patient demonstrate regular urinary elimination patterns
○ Altered thought process
■ Evaluation: Patient maintains reality orientation and communicate clearly
with others
○ Self-care deficit
■ Evaluation: Patient demonstrate regular urinary elimination patterns

24. GLOMERULONEPHRITIS

- is inflammation of the tiny filters in your kidneys (glomeruli).

- NURSING DIAGNOSES
○ Ineffective breathing pattern related to the inflammatory process.
■ Evaluation: Improvement of respiratory rate.
○ Altered urinary elimination related to decreased bladder capacity or irritation
secondary to infection.
■ Evaluation: Excretion of excessive fluid through urination.
○ Excess fluid volume related to a decrease in regulatory mechanisms (renal
failure) with the potential of water.
■ Evaluation: Demonstration of behaviors that would help in excreting
excessive fluids in the body.

25. NEPHROTIC SYNDROME

- is a kidney disorder that causes your body to pass too much protein in the urine.
- NURSING DIAGNOSES
 ○ Excess Fluid Volume related to decreased kidney function
■ Evaluation:
1. Child’s edema will be decreased.
2. Child will achieve ideal body weight without excess fluids.
○ Imbalanced Nutrition: Less Than Body Requirements
■ Evaluation: Client will consume a nutritionally balanced diet.
○ Fatigue related discomfort
■ Evaluation: Child will alternate activity with rest periods.

25. FIFTH DISEASE OR ERYTHEMA INFECTIOSUM

- is a mild rash illness caused by parvovirus B19. It is more common in children than adults.
- NURSING DIAGNOSES
○ Disturbed body image related to a mild rash illness caused by parvovirus B19
■ Evaluation
1. The patient will use learned coping strategies to adjust to a new
reality
2. The patient will recognize self-sabotage and accept help
3. The patient will identify irrational beliefs and use new coping
strategies to enhance perception about body image.
○ Fear related the unkown of mild rash illness as evidenced by patient showing
apprehension, expression of fear that her illness will not go away
■ Evaluation: Client’s fear reduced
○ Deficient knowledge related to the unfamiliarity of a rash illness caused by a
virus
■ Evaluation: Patient demonstrates motivation to learn.
27. POLIO, OR POLIOMYELITIS

- is a disabling and life-threatening disease caused by the poliovirus. The virus spreads from
person to person and can infect a person's spinal cord, causing paralysis (can't move parts of
the body).
- NURSING DIAGNOSES
○ Imbalanced nutrition: less than body requirement related to anorexia, nausea,
and vomiting.
■ Evaluation: The client will be able to improve and maintain a nutritious
diet.
○ Ineffective thermoregulation related to the infection process.
■ The client will be able to maintain adequate thermoregulation.
○ Ineffective airway clearance related to muscle paralysis.
■ Evaluation: The client will be able to clear the airway and breathe
effectively.

28. POLYDACTYLY

- is a deformity in which the hand has one or more extra fingers in any of three places of the
hand

29. TORTICOLLIS
 - is the common term for various conditions of head and neck dystonia, which display specific
variations in head movements (phasic components) characterized by the direction of
movement (horizontal, as if to say "no", or vertical, as if to say "yes").

30. CLUBFOOT

- also known as talipes equinovarus (TEV), is a common foot abnormality, in which the foot
points downward and inward.
- NURSING DIAGNOSES
○ Disturbed body image related to permanent alteration in structure and/or
function.
■ Evaluation: Parents verbalize acceptance of self in the situation
○ Risk for peripheral neurovascular dysfunction related to mechanical
compression (cast or brace).
■ Parents demonstrated an understanding of plan to heal tissue and prevent
injury.
○ Risk for impaired skin integrity related to cast application, traction or surgery.
■ Evaluation: Parents describe measures to protect and heal the tissue,
including wound care.

31. HIP DYSPLASIA

- also known as developmental dysplasia of the hip (DDH), occurs when a baby's hip socket
(acetabulum) is too shallow to cover the head of the thighbone (femoral head) to fit properly.
- NURSING DIAGNOSES
○ Impaired Physical Mobility related to musculoskeletal defect
■ Evaluation: Child will move self in bed with traction bar; walk the length of
the hallway and back twice a day.
 ○ Impaired Social Interaction related to physical mobility restrictions
■ Evaluation:
1. Parent will stay with the infant and renders social interaction.
2. Infant will respond positively to parental interaction.
3. Infant will be included in family activities
○ Constipation related to musculoskeletal impairment
■ Evaluation: Child will maintain passage of soft, formed stool every 1 to 3
days without straining.

32. UMBILICAL HERNIA

- is an abnormal bulge that can be seen or felt at the umbilicus (belly button).
- NURSING DIAGNOSES
○ Acute Pain related to surgical repair
■ Evaluation: Client will express feelings of comfort and reduce pain as
described using a pain scale.
○ Deficient Knowledge related to lack of knowledge about postoperative care
■ Evaluation: Request for information about activity allowed, wound care,
diet, bathing and comfort measures
○ Risk for Injury related to intestinal obstruction
■ Evaluation: Client will not experience injury.

33. OMPHALOCELE

- is a birth defect of the abdominal (belly) wall. The infant's intestines, liver, or other organs stick
outside of the belly through the belly button.
- NURSING DIAGNOSES
○ Acute Pain related to surgical repair
 ■ Evaluation: Client will express feelings of comfort and reduce pain as
described using a pain scale.
○ Deficient Knowledge related to lack of knowledge about postoperative care
■ Evaluation: Request for information about activity allowed, wound care,
diet, bathing and comfort measures
○ Risk for Injury related to intestinal obstruction
■ Evaluation: Client will not experience injury.

34. AN INGUINAL HERNIA

- occurs when tissue, such as part of the intestine, protrudes through a weak spot in the
abdominal muscles.
- NURSING DIAGNOSES
○ Acute Pain related to surgical repair
■ Evaluation: Client will express feelings of comfort and reduce pain as
described using a pain scale.
○ Deficient Knowledge related to lack of knowledge about postoperative care
■ Evaluation: Request for information about activity allowed, wound care,
diet, bathing and comfort measures
○ Risk for Injury related to intestinal obstruction
■ Evaluation: Client will not experience injury.

35. CELIAC DISEASE

- is a serious autoimmune disease that occurs in genetically predisposed people where the
ingestion of gluten leads to damage in the small intestine.
- NURSING DIAGNOSES
○ Diarrhea related to intestinal inflammation
 ■ Evaluation: The patient will be able to return to a more normal stool
consistency and frequency
○ Imbalanced Nutrition: less than Body Requirements related to reduced
absorption of nutrients
■ The patient will be able to achieve a weight within his/her normal BMI
range, demonstration health eating patterns and choices
○ Risk for Fluid Volume Deficit related to poor gastrointestinal absorption of
nutrients related to diarrhea.
■ Evaluation: Patient will be compliant with the dietary regimen and will
verbalize the effects of consuming gluten foods.

36. APPENDICITIS

- is an inflammation of the appendix, a finger-shaped pouch that projects from your colon on the
lower right side of your abdomen.
- NURSING DIAGNOSES
○ Acute pain related to obstructed appendix.
■ Evaluation: Report pain is relieved/controlled..
○ Risk for deficient fluid volume related to preoperative vomiting, postoperative
restrictions.
■ Evaluation: Maintain adequate fluid balance as evidenced by moist
mucous membranes, good skin turgor, stable vital signs, and individually
adequate urinary output.
○ Risk for infection related to ruptured appendix.
■ Eliminating infection due to the potential or actual disruption of the GI
tract.

37. NECROTIZING ENTEROCOLITIS (NEC)

- is a serious gastrointestinal problem that mostly affects premature babies. The condition
inflames intestinal tissue, causing it to die. A hole (perforation) may form in your baby's
intestine.
- NURSING DIAGNOSES
○ Hyperthermia related to inflammatory process/ hypermetabolic state
■ Evaluation: Patient will maintain normal core temperature as evidenced by
vital signs within normal limits and normal WBC level
○ Fluid volume deficit related to failure of regulatory mechanism
■ Evaluation: Patient will be able to maintain fluid volume at a functional
level as evidenced by individually adequate urinary output with normal
specific gravity, stable vital signs, moist mucous membranes, good skin
turgor and prompt capillary refill and resolution of edema.
○ Ineffective tissue perfusion related to impaired transport of oxygen across
alveolar and on capillary membrane
■ Evaluation: Patient will demonstrate increased perfusion as evidenced by
warm and dry skin, strong peripheral pulses, normal vital signs, adequate
urine output and absence of edema