Rotation 1- Pediatrics

NCP

ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION

DIAGNOSIS
OBJECTIVE OF CARE INTERVENTION RATIONALE
CUES:
Ineffective After 8 hours of nursing The goal was met when the patient was
Subjective: airway clearance intervention the patient able to:
The mother related to will be able to:
difficulty of - Maintain patent airway with clear
verbalized that
breathing and - Maintain patent - Assess the rate, - Tachypnea, shallow respirations - At 10 am, for every 2 hours, breath sounds, absence of dyspnea,
her child has:
greenish airway with clear rhythm, depth of and asymmetric chest movement I assessed the patients rate, negative crackles and cleared
- Cough
secretion. breath sounds, respiration, chest are frequently present because of rhythm, depth of respiration, secretions after following doctors
- Colds
absence of movement and use of the discomfort of moving chest chest movement and the use advice.
with dyspnea and accessory muscles wall due to a compensatory of accessory muscles.
greenish - Demonstrate behaviors to achieve
effectively every 2 hours. response to airway obstruction.
secretion airway clearance by doing deep-
clearing secretions.
s for 2 breath exercises using bubble, stuff
weeks - HR and BP increases if fever - At 10:15 am, for every 4
toys and such.
- Develope - Assess vital signs rises. hours, I assessed the
d fever & every 4 hours to see patients vital sign.
- chills changes.
Objective: - Coughing is the most effective - At 10:30am, I checked the
- Assess cough way to remove secretions. cough effectiveness and
Weight: 26.5 lbs
effectiveness and Pneumonia may cause thick and productivity of the patient.
(12kg)
productivity. tenacious secretions in patients.
Vital Signs: - After endorsement for the
Temp: 38.6 C - Follows progress and effects and patient, the next nurse will
PP: 160 bpm extent of pneumonia. Oxygen monitor the chest x-ray,
RP: 60 bpm - Monitor chest x-rays,
saturation should be maintained ABG and pulse oximetry.
O2 Sat: 94% at ABG, Pulse oximetry
at 90% or greater. Imbalances in
room air readings
PaCO2 and Pa02 may indicate
respiratory fatigue. - I administer the medication
Lab Results:
- elevated prescribed by the physician
RBC following the prescribed
5.57x10/ - Administer medication - Medications used to facilitate time and date
- Demonstrate as indicated. respiration by dilating the
L
behaviors to airways.
(Polycyth
achieve airway - Elevate the head of the
emia) - I encouraged the mother of
clearance. bed, change position - Doing so would lower the
- elevated the patient to always elevate
frequently. diaphragm and promote chest
WBC the head of the bed or
expansion, aeration of lung
19.61 elevate the head of the
segments, mobilization, and
- (indicates patient to aid in chest
expectoration of secretions.
infection) expansion.
- Teach and assist
Urinalysis patient and the mother - Taught the patient and
- Facilitates maximum expansion
 ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION
DIAGNOSIS
OBJECTIVE OF INTERVENTION RATIONALE
CARE

CUES: After 8 hours of to do proper deep of lungs, removes secretions and encouraged the mother to The goal was met when the
- + pus Anxiety related to nursing interventionbreathing exercises. patient and family members were
change in reduces chest discomfort. join by using bubbles,
Subjective:
cells the patient will be stuffed toys, pin wheel. able to reduce anxiety and fear
The mother environment as able to: upon the change in environment
Lung X-rayverbalized that her evidenced by fear - Maintain - adequate
Assess child’s and - Provides information - - At 10: 30am, I assessed
Encouraged mother to assist and hospitalization.
upon seeing the - reduce parents’
warm level of about sources and level the
Film: child has: hydration of
- Fluids aidofinanxiety
the mobilization thepatient
patientand guardian’s
in drinking warm
Lung - Cough nurse staff anxiety and fluids to at anxiety,
least 2 –child’s
4 associatedand
to level of anxiety,
fluids every after meal and
fear upon cups. developmental level, expectoration of secretions.
illness and developmental level,
inflammation- Colds with small sips in between.
right upper lobe greenish seeing understanding of hospitalization; sources understanding of illness
consolidation secretions hospital staff illness, and reason of anxiety and and reason for
for 2 weeks specifically for hospitalization, responses differ with hospitalization.
- has - Developed nurses and and responses to this age of child and
difficultyfever & doctor. and prior include separation, pain
of hospitalizations and bodily injury, loss
- chills
breathing during admission. of control, enforced
Objective:
- febrile dependence, fear of
- sweating
Weight: 26.5 lbs - Reduce the unknown, fear of
- lethargic
(12kg) anxiety and equipment, unfamiliar
- decrease fear of environment and
d Vital
breathSigns: family routines, guilt, fear and
sounds &38.6 C
Temp: members concern for child’s
- + PP: 160 bpm recovery, feelings of
- I encouraged the guardian
RP: 60 bpm
crackles powerlessness.
O2 Sat: 94% at - Allow verbalization to assist the patient and to
room air of feelings and voice out their opinion
concerns about - Provides an upon doing my rounds.
Lab Results: condition and opportunity to express
- elevated procedures and feelings and fears to
RBC listen individually to lessen anxiety and
(Polycythem child and parents. promote adjustment to - I encouraged the patient to
ia) hospitalization. share what he feels by
- Allow the child to asking him using a soft
- elevated
play out feelings. tone voice like where does
WBC - Allows the child to
Accept feelings and it hurt?
(indicates reveal feelings without
responses expressed
infection) fear of punishment.
by the child.
Urinalysis - had a fun talk with the
- + pus cells patient explaining that I
- Provide consistent will be his nurse until my
same personnel in - Promotes continuity shift ends.
Lung X-ray Film:
handling written and uniformity of care
Lung inflammation
care plan, care for to sustain a trusting
right upper lobe
child; schedule relationship.
consolidation
personal contact
- has with the child within - Played and talked with the
difficulty of workday. patient to build raport.
breathing
- Interact child in a - Develops rapport and
- sweating
positive approach; trust and maintains
- lethargic
use child’s proper identity.
- decreased name; avoid
breath communicating,
sounds & either verbally or
+ crackles - I encouraged the parents to
nonverbally, any minimize visitors and loud
rejection, judgments, noises to ease the anxiety
or negativism. of the patient.
- Decrease stimuli that