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CASE STUDY PEDIATRIC NURSING CARE IN PATIENT WITH MEDICAL DIAGNOSIS UPPER RESPIRATORY INFECTION AND BILATERAL OTITIS MEDIA
BY: GROUP I
MIRA UTAMI NINGSIH
(130915.216)
RAGIL YUNILA AGNES ANITA P. ANSALMUS ORON WIWIN NURMALANTIKA MEI D F DAEL OLIVIA YOSEFINA A. SAKTI RAHAYU LISA HANDAYANI RUFINA HURAI FREDDI RAMANDA D. MUHAMMAD HARIYADI ILMASARI META KAMELUH I.R. RUDI HARIYONO
(130915.198) (130915.174) (130915.233) (130915.234) (130915.161) (130915.163) (130915.180) (130915.183) (130915.184) (130915.199) (130915.206) (130915.210) (130915.204) (130915.232)
FACULTY OF NURSING AIRLANGGA UNIVERSITY 2009
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PREFACE We really grateful to the Most Glorious and the Most Merciful Allah SWT, we can finished this paper about Pediatric Nursing Care in Patient with Medical Diagnosis Upper Respiratory Infection and Bilateral Otitis Media ontime. This paper written as a part of process in studying English in nursing science and technology. Our appreciation to Dr. Nursalam, M. Nurs (Hons) as our lecturer who has generously provided us with constructive criticism and suggestions to completed this paper. Special thanks to all of our colleagues in class B 12 who have participated in our seminar discussion about the case in this paper. We aware that still there are many lack in this paper so we could use some direction and we always open to your suggestion to make it better. At last, we hope this paper may brings much advantages to all of us.
Surabaya, 9th October 2009
Author
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CONTENTS
Cover ...................................................................................................... i Preface................................................................................................... ii Contents................................................................................................ iii I.
Case ............................................................................................... 1
II.
Pediatric Nursing Care in Patient with Medical Diagnosis Upper Respiratory Infection and Bilateral Otitis Media ............................... 2 A. Assessment ............................................................................... 2 B. Data Analysis and Nursing Diagnosis ........................................ 5 C. Nursing Care Plan...................................................................... 8 D. Implementation ........................................................................ 18 E. Evaluation ............................................................................... 26
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I CASE STUDY
Mrs. King brings 2,5 years-old Billy to the pediatrician’s office because he has been “irritable and feverish since last night.” Further history reveals that Billy also had a runny nose and cough for two days, and that his appetite and fluid intake have decreased since the fever started. Billy is otherwise healthy, this is the first episodic illness. His physical examination reveals slight, irritable, 2,5 years-old boy, crying, pulling at ears, temperature of 1020 F, pulse 100x/minute, respiration rate 35x/minute, nasal congestion with clear discharge, tympanic membranes red and bulging bilaterally, pharynx slightly red without exudates, difficulty vocalizing. Chest clear, abdomen soft without hepatosplenomegali (HSM) and no meningeal sign. The Pediatrician diagnoses an upper respiratory infection (URI) and bilateral otitis media (BOM) and order amoxicillin 250 mg t.d.s for 10 days. You the office nurse, are to perform the parent teaching for Billy’s home care. During your discussion with Mrs. King she tells you that she is concerned that Billy is jealous of his new baby sister because he has occasional tantrums when she holds the baby. She is concerned about Billy development because he recently started to refuse using potty, a skill that is newly acquired. Mrs. King is very attentive to both new baby and Billy throughout the interview, and she asks you for suggestions in how to help Billy cope to the new arrival. While doing so, she points out that her husband has been extra attentive to Billy since his sister was born.
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II PEDIATRIC NURSING CARE IN PATIENT WITH MEDICAL DIAGNOSIS UPPER RESPIRATORY INFECTION AND BILATERAL OTITIS MEDIA
A. ASSESSMENT 1. Patient Identity Name
: “B”
Age
: 2,5 years old
Race
: Java
Religion
: Moslem
Education
:-
Address
: Mulyorejo, Surabaya
2. History Of Present Illness -
Chief Complain : Feverish since last night - Present Illness : Client has been irritable and feverish since last night, he also had a runny nose and cough for two days.
3. Past Nursing History -
History of contagious diseases
: None
-
Hereditary Diseases
:None
-
Allergic history
: None
4. Family Health History Client’s mother said that their family doesn’t have history of contagious diseases and hereditary diseases 5. Observation and Physical Examination -
Vital Sign
:
Temperature: 38,80 C
P : 135 x/minute
RR : 30 x/menit
6
-
BI: BREATHING ( Respiratory System) Complain
: Cough (+), Breathing (-), difficulty vocalizing
RR pattern : Frequency 30 x/mnt, Rhythm : Regular Breathing
: wheezing (-), ronchi (-), secret (+), flares nose (+), hyperemi Faring (+) no exudates, runny nose (+)
Problem -
: Ineffective Airway Clearance
B2: BLEEDING (Cardiovascular System) Complain
: chest pain (-), P = 135 times/minute
Heart sound : Normal Problem -
: None
B3: BRAIN (Nervous System) Orientation
: Person, Time, Place normal
Meningeal sign (-) Awareness
: Composmentis
GCS
: E4 V5 M 6
Eye
: Pupil Isochors, Light reflex (+)
Conjunctiva : Light red
-
Problem
: None
Ear
: Tympani membranes red, bulging bilaterally
Problem
: Acute Pain
B4: BLADDER (Genitourinary System) Complain
: None
Nocturia
: (-)
Fluid intake : Oral 1000cc/day, Parenteral Problem -
: 750 cc/day
: None
B5: BOWEL (Gastrointestinal System) Mouth
: Pharynx slightly red, Stomatitis(+)
Complain
: Abdomen(-),Alvi elimination(-).
Weight
: 13 kg
High : 100 cm
7
Nutrition
: Eat 2x/day Portion : 3-5 spoon (half of portion)
Problem -
-
: Altered nutrition; less than body requirement
B6: BONE (Bone – Muscle – Integument) Joint Activity
: Free
Back Injury
: None,
Integuments
: Skin feels hot, T: 38,80C
Acral
: Warm
Turgor
: Excellent
Problem
: Hyperthermia
Psycho-social Client’s mother said that he is jealous of his new baby sister because he has occasional tantrums when she holds the baby. Client’s mother is concerned about client’s development because he recently started to refuse using potty, a skill that is newly acquired. Client crying and seems irritable.
-
Endocrine System Complain : None
6. Laboratorium Blood •
Hb
: 11,9
•
PLT
: 160
•
WBC
: 13,2
•
RBC
: 3,00
•
PCV
: 37,4
Urine : Leukosit : 1-3 7. Radiologi : Thorax photo Normal
8
8. Therapy : •
Amoxicillin 250 t.d.s
•
Oxymetazoline 2 drop twice a day
•
Paracetamol 250mg t.d.s
B. DATA ANALYSIS DATA
ETIOLOGY
Subjective Data
Increase metabolism
Client’s mother said
secondary to disease/
that he has been
PROBLEMS Hypertermia
infection process
irritable and feverish since last night. Objective Data Temperature of 1020 F Tympanic membranes red and bulging bilaterally Pharynx slightly red without exudates Lab test WBC :13,2 K/UL Subjective:
Infection in medial ear
Client’s mother said that Billy
has been
tension in medial ear
irritable and feverish since last night Objective Client’s seems irri-
press the tympanic membrane
Acute pain
9
table, crying
tympanic membrane
Pulling at ears
bulging bilaterally
tympanic membranes red
and
bulging
Pain
bilaterally
Subjective:
Less appetite and
Altered nutrition: Risk
Client’s mother said
increased metabolism
for
that his appetite and
secondary to disease
requirements
fluid
intake
have
less
than
body
process
decrease since the fever started. Client’s mother said that he only finished a half of his meals Objective: Pharynx slightly red without exudates Subjective
Retained secret and
Client’s mother said edema of nasal mucous that he had runny nose and cough two days. Objective Nasal
congestion
with clear discharge The
client’s
perform
can’t
effective
cough Difficulty vocalizing
Ineffective clearance
airway
10
Subjective Data
Sibling
complex;
Client’s mother said new arrival in family
The Family coping: risk for growth
that Billy is jealous of his new baby sister because
he
has
occasional tantrums when she holds the baby Client’s mother said that
Billy
started
to
recently refuse
using potty
C. NURSING DIAGNOSTIC 1. Ineffective airway clearance related to retained secret and edema of nasal mucous, signed by client’s mother said that he had runny nose and cough two days, nasal congestion with clear discharge, client can’t perform effective cough, difficulty vocalizing 2. Acute pain related to increasing of tension in middle ear secondary to infection process signed by client’s mother said that Billy has been irritable and feverish since last night, client’s mother said that his appetite has decrease, client seems irritable, pulling at ears, tympanic membranes red and bulging bilaterally 3. Hyperthermia related to Increase metabolism secondary to disease/ infection process signed by Client’s mother said that he has been irritable and feverish since last night, temperature of 102 0 F, tympanic membranes red and bulging bilaterally, pharynx slightly red without exudates. 4. Altered nutrition: Risk for less than body requirement related to decreased appetite and the increased metabolism secondary to disease process signed by client’s mother said that his appetite and
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fluid intake have decrease since the fever started, client’s mother said that he only finished a half of his meals, pharynx slightly red without exudates 5. Family coping: risk for growth related to sibling complex; the new arrival in family signed by client’s mother said that Billy is jealous of his new baby sister because he has occasional tantrums when she holds the baby, client’s mother said that Billy recently refuse using potty
C. PLANNING Dx
1
Expected Outcomes
Nursing Orders
Demonstrate
1. Monitoring
adequate air
respiratory
exchange, as
rate, depth
Rationale
1. Tachypnea is usually status;
present
to
some
degree and may be
evidence by:
pronounced
a. Use of correct
respiratory stress.
breathing/coughi 2. Monitoring ng technique
during
vital 2. Inadequate
sign
oxygenation
cause
increased pulse rate. b. Productive cough c. Client’s and care
3. Evaluate
amount 3. Excessive
and type of secre-
sticky
tions
make it difficult to
being
pro-
duce
to help client to maintain patent airway.
mucus
maintain
giver know and understand how
and/or can
effective
airways 4. Assess
client’s/ 4. To determine aduca-
caregiver
know-
ledge
contri-
of
buting treatment
causes, plan,
tional needs
12
specific tion
medica-
and
thera-
peutic procedures 5. inform
client/ 5. Repositioning
caregiver
to posi-
tionning
client’s
head for
appropriate age
and
condition/ disorder
head
may, at times, be all that
is
open
needed or
to
maintain
open airway in at-rest or
compromised
individual,
such
as
one with sleep apnea 6. inform care
client giver
or 6. Cold water or fluid to
can lower the verge
maintain adequate
limit of allergic and
fluid
intake
make
especially
warm
congestion worse
nasal
fluid. 7. Administer
7. Expectorant
helps
prescribed
loosen secretions so
expectorant,
they can be coughed
decongestant
or
anti histamine
up
an
wxpelled.
Decongestant and or anti
histamine
can
helps reduce mucous edema
and
nasal
congestion 8. Discuss
important 8. Discipline in following
of following
the
therapeu-tic procedure schedule 9. Inform
the
therapeutic
procedure deter-mine as
its
the
success
of
therapy client/ 9. Knowledge
about
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caregiver about the
medication
medication
increase
procedure the
client/care-
(e.g.,
giver discipline, avoid
of
anxiety related to side
use
medicine, effect,
can
side schedule,
dosage)
effect
of
medicine
and also determine the
success
of
therapy 2
Demonstrate a
1. Note client’s age/ 1. affecting
ability
decrease in
developmental
report
symptoms/
level and current
parameters
complaints as note
condition
in defining
infant/child,
characteristic
critically ill)
a. Demonstrate of
pain
(e.g.,
2. Obtain
client’s 2. identify precipitating/
relaxation
assessment of pain
aggravating
attitude.
to include location,
relieving factors
b. Client or care-
and
characteristic,
giver under-
onset/
stand and
quality, intensitivity.
demonstrate the
to
duration,
3. Note possible pa- 3. acute
pain
which
way to reduce
thophysiological/
follows
an
injury/
pain
psychological
trauma
or
occurs
c. Follow
causes
of
pain
suddenly
prescribed
(e.g., inflammation,
onset
pharmacological
trauma,
condition
regimen
process) 4. Use scale
infection
pain
with of
rating 4. assessment
the
painful
pain
appropriate
scale helps to plan
for age/ cognition
the suitable way to
(e.g.,
relieve pain
facial
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expression/WongBaker faces pain scale for pediatric or
nonverbal,
behavior
pain
scale) 5. Observe nonverbal 5. identify behaviors that cues
(e.g.,
how
may indicate pain in
client walks, holds
persons who cannot
body,
communicate
guarding
behaviors,
gri-
verbally.
Helpful
in
macing
facial,
recognizing presence
narrowed
focus;
of pain
crying, lethargy in infant) 6. Monitor vital signs 6. Blood
pressure,
during episodes of
respiratory and heart
pain
rate
are
usually
altered in acute pain 7. Administer analgesic
7. The to
type
medication
of ordered
maximal dosage as
depends on the type
“acceptable”
and severity of pain.
level
of pain and inform
Knowledge
client or caregiver
medication procedure
about
increase
the
of
client/
medication
caregiver cooperation
procedure
in therapy.
8. Teach caregiver to 8. For client who cannot note the cues of
verbalizing pain, the
pain
to
caregiver should note
manage comfort for
the cues of pain to
and
15
client
start manage comfort to reduce pain and helps
client
maintain
to
positive
coping against pain 9. Teach
client
or 9. Some
Temperature in
(e.g.,
care-giver to helps
swallowing, yawning)
client demonstrate
can cause opening
way
eustachius tube that
to
maintain
same pressure in
make
ear (e.g., promote
pressure
swallowing
reduce bulging and
or
yawning) 3
way
1. Note
the
same in
ear,
pain.
chronological 1. Infants, young chil-
normal range as
and developmental
dren
evidence by:
age of client
persons
a. Maintain core
and
elderly
are
most
susceptible to dama-
temperature
ging
within normal
Environmental factors
range
and relatively minor
b. Demonstrate
hyperthermia.
infections
can
pro-
behaviors to
duce a much higher
monitor and
temperature in infants
promote
and young children
normothermia
than in older children
c. Client and care-
and adults
giver understand 2. Monitor core tem- 2. To gain valid data and able to
perature by appro-
about the presence of
mention ways to
priate route
temperature elevation
promote
(>98.6ºF [37ºC]) or
normothermia
fever
(100.4ºF
16
[38ºC]). 3. Teach parents how 3. Low
grade
fever
to measure child’s
enhances
temperature,
at
system functioning in
what body tempe-
presence of infection
rature
give
and is not harmful as
antipyretic medica-
long as individual is
tions,
not
to
and
what
immune
dehydrated
or
symptoms to report
susceptible to febrile
to physician
seizures. Fever may be treated at home to relieve
the
general
discomfort lethargy
and associated
with fever. Fever is reportable, especially
however, if
it
unresponsive
is to
antipyretics and fluids, because
it
often
accompanies
a
treatable
infec-tion
(viral or bacterial) 4. Discuss importance 4. Adequate fluid intake of
adequate
fluid
needs to replace fluids
intake at all times
lost through perspira-
and
to
tion
hydration
and
improve
ways
status when ill or when under stress (e.g., exercise, hot environment).
and to
dehydration
respiration avoid
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5. Instruct
families/ 5. Heat injuries can be
caregivers (of young
immediately
life-
children,
threatening.
Being
persons
who are outdoors in
aware
very
climate)
mental hazards and
dangers of heat ex-
hydration levels can
haustion and heat-
save one’s life
hot
of
environ-
stroke and ways to manage hot environments. parents
Instruct to
avoid
leaving young children in unattended car 6. Teach
client
caregiver
or 6. Enable to
promote cooling by
client
or
caregiver to promote cooling.
means of: a. Limiting
a. Encourage
clothing/dress
in
lightweight,
loss
heat
by radiation
and conduction
loose-fitting clothes. b. Cool the environment
with
air
conditioning
or
b. Promotes heat loss by convection
fans c. Provide cool/tepid
c. Heat loss by eva-
sponge baths or
poration and con-
immersion if
duction.
temperature is
pediatric
>1040F or local
tepid water is pre-
Note:
in
clients,
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ice packs,
ferred.
Alcohol
especially in groin
sponge baths are
and axille (areas
contraindicated
of high blood
because they in-
flow)
crease
peripheral
vascular constricttion
and
CNS
depression;
cold-
water
sponges/
immersion
can
increase shivering, producing heat. d. Keep clothing
d. To
and linens dry
reduce
shivering
7. Administer medica- 7. To
manage
tions (e.g., dantro-
thermia,
lene,
chlorproma-
shivering
zine, or diazepam)
seizures.
hypercontrol and
as ordered
4
Demonstrate
un- 1. Assess client/care- 1. Identifies
derstanding
in
teaching
giver knowledge of
needs and/or helps
avoid altered nutri-
nutritional
guide
tion; risk for less
and ways client is
than body require-
meeting
ments. As eviden-
needs.
ce by: a. Client/ caregiver
2. Teach giver
needs
choice
of
intervention.
these
client/care- 2. Increase appetite can way
to
in-
increase the nutrition
verbalizing
crease appetite:
intake.
understanding
a. Determine when
a. To promote sense
how to keep
client
prefers/
of control and give
19
adequate
tolerates largest
client
nutrition intake
meal of the day.
to
for client
Maintain
feeling
b. Client finished all of his meal c. Present weight in control
flexi-
opportunity eat
when more
bility in timing of
rested, less pain
food intake
or nausea
b. Provide
nume-
b. Reduce feeling of
rous small feed-
fullness that can
ings, as indica-
accompany larger
ted; supplement
meals,
and
with
improve
chances
easily
di-
gested snack
to
of increasing the amount of nutrients
taken
over
24-hour period c. Encourage riety
in
choice,
vafood
varying
textures
c. Enhance
food
satisfaction
and
stimulate appetite.
and
taste sensations (e.g. sweet, salty,
fresh,
me-
thods of cooking) 3. Suggest client/care- 3. To enhance intake, giver
to
specific
increase
specific
nutrients
(e.g.,
nutrients protein,
vita-
(e.g., protein, carbo-
mins) are needed to
hydrates, fats and
help
calories), as need-
illness
ed, providing client
infection
with preferred food and
seasoning
recovery or
from
against
20
choices
where
possible 4. Suggest client/caregiver
to
promote
adequate/timely
4. Fluid is essential to the digestive process and is often taken
fluid intake
with
meals.
may
need
Fluids to
be
withheld before meals or
with
meals
if
interfering with food intake 5
1. Discuss family
1. Expectation of client
Demonstrate
perceptions of
and family members
effective family
situation
may/may not be
Client/caregiver
coping
realistic and may
Outcome criteria:
interfere with ability to
a. Client/ family
deal with situation
can verbalize
2. Identify current be- 2. Indicators of extent of
the way to cope
haviors of the family
problems existing with-
the situation
members (e.g., ig-
in
b. Family/parents
noring/ caring client
ships
verbalizing their
at home; anger and
members before and
understanding
ways
touching
after current new born
of growth
between
family
affect ability to deal
process in
members,
toddler
expressions)
of
care
3. Suggest family to
with
family.
Relation-
among
family
problems
of
caretaking 3. Getting involve in
involve client in
taking care of the new
taking care of the
baby help client to find
new baby
his new role in family as a brother and also
21
feels posses 4. Suggest family to
4. Same attention and
give the same
care help to avoid
attention and care
jealousy
to both client and the new baby 5. Explain family about 5. Helping family/ parents toddler growth
to take care of client appropriate to client growth.
6. Explain family/ pa- 6. Good rents
about
the
communication
make
it
easier
for
importance of deve-
family to teach client
loping good com-
skill that is appropriate
munication between
to his growth (e.g.,
parents and child
using potty)
D. IMPLEMENTING
Nursing diagnosis
1. Ineffective way
to
Respond
air- 1. Monitoring respiratory 1. Respiration rate 35x/
clearance
related
Implementation
status; rate, depth
minute.
Difficulty
in
re-
respiration because of
tained secret and
nasal congestion with
edema of nasal
clear discharge. Client
mucous
has runny nose 2. Monitoring vital sign
2. RR: 35x/minute, pulse: 100x/minute, temperature: 1020 F
3. Evaluating
amount 3. Clear discharge from
22
and type of secretions
nasal.
Client
cannot
being produce.
expel the secretion by coughing it up
4. Assessing client/care- 4. Client’s giver
knowledge
contributing
parents
said
of
that they really concern
causes,
about client condition
plan,
and don’t know about
treatment specific
medication
and
therapeutic
the medication
procedures 5. informing client/care- 5. Client’s giver
to positioning
parents
said
that they understand
client’s head appro-
and
priate for age and
suggestion
will
follow
the
parents
said
condition/ disorder 6. informing
client
or 6. Client’s
caregiver to maintain
that they understand
adequate fluid intake
and
especially warm fluid.
suggestion
7. Administering cribed
will
follow
the
pres- 7. Client is given Oxyme-
expectorant,
de-congestant or anti
tazolone 2 drops twice a day
histamine 8. Discussing important 8. Client’s of
following
parents
said
the
that they understand
therapeutic procedure
and will maintain their
as it scheduled
child
to
follow
therapeutic
the
procedure
as it scheduled 9. Informing client/care- 9. Client’s giver
about
the
medication procedure
parents
said
that they understand of information
that
has
23
(e.g.,
the
use
of
given.
medicine, side effect, schedule, dosage) 2. Acute
pain
re- 1. Noting client’s age/ 1. Client at age of 2.5
lated
to
incre-
developmental
asing
of
pres-
and current condition
sure
in
middle
ear secondary to
(e.g.,
infant/
level
years old
child,
critically ill)
infection process 2. Noting possible pa- 2. From
physical
thophysiological/ psy-
examination
chological causes of
tympanic
pain
inflame-
red
trauma,
bilaterally.
Client
diagnosed
bilateral
(e.g.,
mation,
infection process)
otitis
revealed membrane
and
bulging
media
by
pediatrician 3. Observing nonverbal 3. Client seems irritable, cues (e.g., how client
pulling at ears, and
walks,
crying.
holds
guarding
body,
behaviors,
grimacing
facial,
narrowed
focus;
crying,
lethargy
in
infant) 4. Monitor during
vital
signs 4. RR: 35x/minute, pulse
episodes
of
temperature 1020F
pain 5. Administering gesic dosage
100x/minute,
to as
anal- 5. Client is given paramaximal
cetamol 250 mg t.d.s
“accep-
and amoxicillin 250 mg
table” level of pain
t.d.s for 10 days.
24
and inform client or caregiver about the medication procedure and antibiotics to cure the infection 6. Teaching caregiver to 6. Client’s
parents
can
note the cues of pain
mention some kind of
and
cues of pain and the
to
manage
comfort for client
way to manage comfort for client to reduce pain
7. Teaching
client
caregiver client
to
or 7. Client’s parents under-
helps
demonstrate
stand and know how to helps
their
child
to
way to maintain same
demonstrate the way to
pressure in ear (e.g.,
maintain
promote
pressure in ear.
swallowing
same
or yawning)
3. Hyperthermia re- 1. Noting
chronological 1. Client at age of 2.5
lated to Increae
and
metabolism
age of client
secondary
developmental
years old. His mother said that he has been
to
feverish since last night
disease/infection 2. Monitoring core tem- 2. Temperature 1020F process
perature by appropriate route 3. Teaching parents how 3. Client’s to
measure
child’s
parents
demonstrate
how
can to
temperature, at what
measure
body temperature to
temperature and know
give antipyretic medi-
when the temperature
cations,
need antipyretic medi-
and
what
child’s
25
symptoms to report to
cation
and
what
physician
symptoms need to be reported to physician
4. Discussing importance 4. Client’s of
adequate
parents
ex-
fluid
press the understand-
intake at all times and
ding of importance of
ways
adequate fluid intake
to
improve
hydration status when ill
or
when
under
stress (e.g., exercise, hot environment). families/ 5. Client’s
5. Informing
parents
said
caregivers (of young
that they understand of
children, persons who
the information that has
are outdoors in very
given
hot climate) in dangers of heat exhaustion and heat-stroke and ways to manage hot environments. parents
Instructing to
avoid
leaving young children in unattended car 6. Teaching
or 6. Client’s
client
parents
caregiver to promote
express understanding
cooling by means of:
and
a. Limiting
promoting cooling for
clothing/dress lightweight,
in loose-
fitting clothes. b. Cooling ronment
the with
enviair
knowledge
their child
in
26
conditioning or fans c. Providing cool/tepid sponge
baths
or
immersion if temperature is >1040F or local
ice
packs,
especially in groin and axillae (areas of high blood flow) 4. Altered nutrition: 1. Assessing client/care- 1. Client’s parents said Risk
for
than
body
quirement
less
giver
knowledge
of
that they really concern
re-
nutritional needs and
about
relat-
ways client is meeting
nutrition and know that
these needs.
their
ed to decreased
their
child
child
need
appetite and the
adequate nutri-tion for
increased meta-
his
bolism
development
second-
dary to disease 2. Teaching process
growth
and
client/care- 2. Client’s parents said
giver ways to increase
that they understand
appetite:
and will try to do some
a. Determining when
ways to increase their
client prefers/ tolerates largest meal of the day. Maintain flexibility in timing of food intake b. Providing rous
nume-
small
feed-
ings, as indicated; supplements easily
with
digested
child’s appetite
27
snack c. Encouraging variety in food choice, varying
textures
and taste sensetions (e.g., sweet, salty,
fresh,
me-
thods of cooking) client/care- 3. Client’s
3. Suggest
parents
giver to increase spe-
verbalizing
their
cific
understanding
and
nutrients
(e.g.,
protein, carbohydrates,
willingness to provide
fats and calories), as
more specific nutrients
needed,
providing
for their child.
client
preferred
food
with and
seasoning
choices
where
possible client/care- 4. Client’s
4. Suggest giver
to
promote
their
verbalizing
willingness
to
adequate/ timely fluid
promote
adequate/
intake
timely fluid intake for their child
5. Family
coping; 1. Discussing family
1. Client’s family said that
risk for growth
perceptions of
they really concern of
related to sib-
situation
client growth and that
ling
complex;
this situation can affect
the new arrival in family
in client growth 2. Identify current
2. Client’s
mother
said
behaviors of the family
that indeed, after the
members (e.g.,
new born, she spent
28
ignoring/ caring client
more time to take care
at home; anger and
of the new baby than to
ways of touching
client. But his husband
between family
has
members, care
attentive to client
been
extra
expressions) 3. Suggest family to
3. Client’s family said that
involve client in taking
they will involve client
care of the new baby
in taking care of the new baby
4. Suggest family to give 4. Client’s family said that the same attention and
they will give the same
care to both client and
attention and care to
the new baby
both client and the new baby
especially
for
client’s mother 5. Explain family about
5. Family
toddler growth
understand
about toddler growth
6. Explain family/ parents 6. Family understand and about the importance
will
develop
good
of developing good
communication
with
communication
their child
between parents and child
E. EVALUATION Nursing Diagnosis 1
Evaluation
S: -
Client’s parents said that they understand and will
29
follow the suggestion -
Client’s parents said that they understand and will maintain their child to follow the therapeutic procedure as it scheduled
O: -
Respiration rate 35x/minute
-
Difficulty in respiration because of nasal congestion with clear discharge
-
Client has runny nose
-
Client cannot expel the secretion by coughing it up
A: Goal met partially P: Continuing intervention and Modification to plan of care 2
S: -
Client’s parents said that they understand and know how to helps their child to demonstrate the way to maintain same pressure in ear
O: -
Tympanic membrane red and bulging bilaterally
-
Client seems irritable, pulling at ears and crying
-
RR: 35x/minute, pulse 100x/minute, temperature 1020F
-
Client’s parents can mention some kind of cues of pain and the way to manage comfort for client to reduce pain
A: Goal met partially P: continuing intervention and modification to plan care 3
S: -
Client’s parents understand and know how to helps their child to demonstrate the way to maintain same pressure in ear
O:
30
-
Client’s parents can demonstrate how to measure child’s temperature and know when the temperature need antipyretic medication and what symptoms need to be reported to physician
-
Client’s parents express understanding and knowledge in promoting cooling for their child
-
Client seems irritable, pulling at ears and crying
-
RR: 35x/minute, pulse 100x/minute, temperature 1020F
A: Goal met partially P: Continuing intervention and modification to plan care
4
S: -
Client’s parents said that they understand and will try to do some ways to increase their child’s appetite
-
Client’s parents verbalizing their understanding and willingness to provide more specific nutrients for their child.
-
Client’s
verbalizing
their
willingness
to
promote
adequate/ timely fluid intake for their child O: -
Client/ caregiver verbalizing understanding how to keep adequate nutrition intake
A : Goal met partially P
:
Continuing intervention for client homecare
and
modification to plan care 5
S: -
Client’s family said that they will involve client in taking care of the new baby
-
Client’s family said that they will give the same attention and care to both client and the new baby
31
especially for client’s mother -
Family understand about toddler growth
-
Family understand and will develop good communication with their child
O: -
Family can verbalize the way to cope and their willing to cope the situation
-
Family/parents verbalizing their understanding of their child growth
A : Goal meet P : Intervention stopped
