Nursing Care Plan

Group 1 and 4
Case Scenario
A case of 2 year old male brought
by his mother at the emergency room
due to dyspnea , puffy eyelids, flank
pain and tea-colored urine. Upon
assessment, patient was noted to have
scabies at both lower extremities . The
following are the doctor’s order:
1. CBC, urinalysis, BUN, creatinine,
total protein AG ratio, chest x-ray
2. Strictly monitor intake and output
3. Weigh daily
Patient’s Name: KAV

Rm. #: Pediatric Ward

Age: 2 years old

C/C: Dyspnea

Diagnosis:Acute Poststreptococcal Glomerulonephritis

Doctor: Dr. U.
 General Objective:
To facilitate the maintenance of oxygen
supply to all body cells
Subjective Cues
As verbalized by the mother:

“Di siya mayo kaginhawa”

“Di siya mayo katulog”
“Pirme lang siya gahibi”
“Gahungag ang iya ilong”
“Ginahapo siya biskan wala siya may gin
ubra.”
Objective Cues
Pale skin
Restlessness
Nasal Flaring
Temp. 37.9C (37.5 C)
RR: 72 cpm (32-60 cpm)
HR: 135 bpm (app. 80-110 bpm)
 Weight: 11.5 lbs or 5 kg; increasing to 0.3
lbs/day (approx.11.7 lbs)
BP: 110/80 mmHg (105/55-70 mmHg)
Others:
Chest x-ray result revealed pulmonary edema with leaka
ge of fluid into the interstitium, alveoli and pleural space
 Hgb- 10.2 g/dL (12.5 g/dL) 2-6 yrs old
 Hct- 29.6% ( 34-40%) 2-6 yrs old
 BUN- 22 mg/dL (5-18 mg/dL)
 Creatinine- .9 mg/dL ( under .5 mg/dL)
 WBC- 11,100 WBCs/mL (4,500-11,000 WBCs/mL
 Total protein AG ratio - 5.9 g/dL (6.3-8.2 g/dL)
 U/O- 20 mL/hr (500-600 mL/day or approx. 23 mL/hr)
 NURSING RATIONALE SPECIFIC
DIAGNOSIS GOAL

Altered breathing Due to Sarcoptes Scabiei infestation skin int Within 4 days
pattern: Dyspnea egrity is compromised causing bacterial gro of rendering
related to fluid wth streptococcus in the body’s systemic ci nursing care
retention rculation. Inflammation of the glomeruli of the client will
secondary to Acute the kidney occurs as an immune complex di display
Poststreptococcal sease after infection with nephritogenic stre normal
Glomerulonephritis ptococci. Tissue damage occurs from a com breathing
plement fixation reaction a cascade of prot pattern
ein activated by antigen-antibody reaction
plugs and obstructs the glomeruli causing k
idney damage leading to water retention in
creasing systemic blood volume and cardia
c workload thus increase in heart rate result
ing inefficient pumping of the heart leading
to the lungs causing pulmonary congestion
during respiratory congestion there would
be insufficient gas exchange resulting dysp
nea, low O2 saturation, restlessness and inc
rease respiratory rate.
 INTERVENTION RATIONALE

INDEPENDENT
•Assess the level of consciousness and skin tone. •To evaluate the changes in gas exchange which
affects the level of consciousness and skin tone.

•Notefor respiratory rate, depth, use of accessory • To evaluate degree of compromise

muscles, pursed-lip breathing.

• Assist client in proper deep breathing exercise • To promote good lung expansion

• Position the client in semi-fowler’s position by eleva •To prevent compression of the diaphragm by allowin
ting the head of the bed g the organs in the peritoneal cavity to lower down.

•To evaluate presence/character of breath sounds and

•Auscultate chest. secretions.

• To avoid overexertion
• Encourage adequate rest periods between activities
•To promote proper breathing/ to prevent obstruction
• Instruct significant others not to let the child wear of circulation
tight clothing.
• To prevent cause of abdominal distention.
•InstructSO not to let the client overeat and eat gas-
forming foods.
• To limit impact on client's breathing.
•Educate SO about environmental factors that may
trigger disease of the patient
•Anxiety may be causing acute or chronic
•Note emotional responses(e.g., gasping, crying, hyperventilation.
reports of tingling fingers)
 INTERVENTION RATIONALE
COLLABORATIVE
• Administer diuretic (furosemide) • To increase water excretion
IV/stock 40mg/2mL/0.3cc every 1
2 hours, as ordered.

•Administer
oxygen at lowest •For management of underlying
concentration indicated and pulmonary condition, respiratory
prescribed repiratory medications. distress.

•Monitor pulse oximetry, as •To verify maintenance/

indicated. improvement in O2 saturation
 EVALUATION
After 4 days of rendering effective nursing
care, the client with altered breathing patt
ern was able to restore normal breathing
by evidence of absence of nasal flaring, n
o restlessness, no pale skin with respirato
ry rate of 40 cpm, with the temperature of
37 C, and heart rate of 90 bpm, with the
BP of 100/70 mmHg. Chest x-ray shows n
egativity of fluid retention in the lungs.