Pediatric Nursing Care (case Study)

1

CASE STUDY PEDIATRIC NURSING CARE IN PATIENT WITH MEDICAL DIAGNOSIS UPPER RESPIRATORY INFECTION AND BILATERAL OTITIS MEDIA

BY: GROUP I

MIRA UTAMI NINGSIH 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

(130915.216) (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

3

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

4

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. 1. Past Nursing History –

History of contagious diseases

: None

–

Hereditary Diseases

:None

–

Allergic history

: None

1. Family Health History

Client’s mother said that their family doesn’t have history of contagious diseases and hereditary diseases 2. 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

Nutrition

: Eat 2x/day Portion : 3-5 spoon (half of portion)

High : 100 cm

7

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

1. Laboratorium Blood Hb

: 11,9

•

PLT

: 160

•

WBC

: 13,2

•

RBC

: 3,00

•

PCV

: 37,4

•

Urine : Leukosit : 1-3 1. Radiologi :

Thorax photo Normal 2. Therapy : •

Amoxicillin 250 t.d.s

•

Oxymetazoline 2 drop twice a day

8

Paracetamol 250mg t.d.s

•

A. DATA ANALYSIS DATA

ETIOLOGY

Subjective Data

Increase metabolism

Client’s

mother

said that he has been

irritable

and

feverish

PROBLEMS

Hypertermia

secondary to disease/ infection process

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 said

mother

that

Billy

has been irritable and

feverish

tension in medial ear

Acute pain

9

since last night Objective

press the tympanic

Client’s

seems

membrane

irri-table, crying Pulling at ears

tympanic membrane

tympanic membranes red and

bulging

bilaterally

Pain

Subjective:

Less appetite and

Client’s said

bulging bilaterally

mother that

his

appetite and fluid intake

have

decrease

since

Altered nutrition: Risk

increased metabolism

for

less

than

secondary to disease

requirements

body

process

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

Ineffective

airway

10

Client’s

mother edema of nasal mucous

clearance

said that he had runny nose and cough two days. Objective Nasal congestion with

clear

discharge The client’s can’t perform effective cough Difficulty vocalizing

Subjective Data Client’s

Sibling mother

said that Billy is jealous

of

his

new baby sister because he has occasional tantrums she

when

holds

the

baby Client’s said

mother

that

recently

Billy

started

to refuse using potty

complex;

new arrival in family

The Family coping: risk for growth

11

A. 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 1020 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 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

Expected Outcomes Demonstrate

Nursing Orders

1. Monitoring

Rationale

1. Tachypnea

is

12

1

adequate air

respiratory

exchange, as

status;

evidence by:

depth

a. Use

usually rate,

to some degree and

of

present may

be

pronounced

correct

during respiratory

breathing/co

stress.

ughing technique

2. Monitoring

vital

sign

pulse rate. 3. Evaluate amount

and c. Client’s and

care giver

type

of

secre-tions

3. Excessive and/or sticky mucus can make it difficult to maintain effective

being pro-duce

airways

know and

4. To

understand how to help

oxygenation cause increased

b. Productive

cough

2. Inadequate

4. Assess

client’s/

client to

caregiver know-

maintain

ledge of contri-

patent

buting

airway.

treatment

determine

aduca-tional needs

causes, plan,

specific medication and therapeutic procedures 5. inform

client/

caregiver

to 5. Repositioning

posi-tionning client’s appropriate age

head for and

head

may,

at

times, be all that is

needed

to

condition/

open or maintain

disorder

open airway in

13

at-rest

or

compromised individual, 6. inform client or

care

giver

to

maintain

as one with sleep apnea 6. Cold

adequate

such

water

or

fluid

fluid can lower

intake especially

the verge limit of

warm fluid.

allergic

7. Administer

and

make

prescribed

nasal

congestion worse

expectorant, decongestant or anti histamine

7. Expectorant

helps

loosen

secretions

so

they

be

can

coughed up an wxpelled. Decongestant and 8. Discuss important

of

following

the

therapeu-tic procedure as its schedule 9. Inform

client/

caregiver about the

medication

procedure (e.g., the

use

medicine,

of side

effect, schedule,

or

anti

histamine

can

helps

reduce

mucous

edema

and

nasal

congestion 8. Discipline following

in the

therapeutic procedure determine the success of therapy 9. Knowledge about

medication

can

14

dosage)

increase client/care-giver discipline,

avoid

anxiety related to side

effect

medicine also

of and

determine

the success of therapy 2

Demonstrate a

1. Note

client’s

1. affecting ability to

decrease in

age/

report

symptoms/

developmental

parameters

complaints as note

level

in defining

current

characteristic

condition (e.g.,

a. Demonstrat e of relaxation

pain

and

infant/child, critically ill) 2. Obtain client’s

2. identify

attitude.

assessment of

precipitating/

b. Client or

pain to include

aggravating and

care-giver

location,

relieving factors

under-stand

characteristic,

and

onset/

demonstrat

duration,

e the way to

quality,

reduce pain

intensitivity.

c. Follow

3. Note

possible

3. acute pain which

prescribed

pa-

follows an injury/

pharmacolo

thophysiologic

trauma or occurs

gical

al/

suddenly with the

regimen

psychological

onset of painful

causes of pain

condition

15

(e.g., inflammation,

4. assessment pain

trauma,

scale

infection

helps

to

plan the suitable

process) 4. Use pain rating

scale

way

to

relieve

pain

appropriate for age/ cognition (e.g.,

facial

expression/Wo ng-Baker faces pain scale for pediatric

or

nonverbal, behavior

pain

scale)

5. identify behaviors that may indicate pain in persons

5. Observe

who

nonverbal cues

(e.g.,

how

client

walks,

holds

body, guarding

cannot

communicate verbally. Helpful in

recognizing

presence of pain

behaviors, grimacing facial, narrowed focus;

crying,

lethargy

in

infant) 6. Monitor

signs

vital during

episodes pain

of

6. Blood

pressure,

respiratory

and

heart

are

rate

usually altered in acute pain 7. The

type

of

medication ordered depends

16

on the type and severity of pain.

7. Administer

analgesic

to

maximal dosage

as

“acceptable” level of pain and

inform

client

or

caregiver about

the

medication

procedure increase

client/

caregiver cooperation

in

therapy. 8. For

client

who

cannot verbalizing pain, caregiver

should note the

8. Teach

to

note the cues of pain and to manage comfort

of

medication

the

procedure caregiver

Knowledge

for

client

cues of pain to start

manage

comfort to reduce pain and helps client to maintain positive

coping

against pain 9. Some way (e.g.,

swallowing, yawning) cause

can opening

eustachius that 9. Teach client or

care-giver helps

to

client

demonstrate way

to

maintain same

make

tube the

same pressure in ear,

reduce

bulging and pain.

17

pressure in ear (e.g., promote swallowing

or

yawning) 3

Temperature in

1. Note

1. Infants,

young

normal range as

chronological

chil-dren

evidence by:

and

elderly

developmental

are

age of client

susceptible

a. Maintain core

and persons most to

temperature

dama-ging

within

hyperthermia.

normal

Environmental

range

factors

and

b. Demonstrat

relatively

minor

e behaviors

infections

can

to monitor

pro-duce a much

and

higher

promote

temperature

normotherm

infants

and

ia

young

children

c. Client and

than

in

care-giver

children

understand

adults

and able to mention ways to promote normotherm ia

2. To 2. Monitor

core

tem-perature by appro-priate route

gain

in

older and valid

data about the presence

of

temperature elevation (>98.6ºF [37ºC]) or fever (100.4ºF [38ºC]). 3. Low grade fever

18

enhances 3. Teach

parents

how to measure child’s temperature, what

body

tempe-rature give

at to

antipyretic

medica-tions, and

what

symptoms

to

report

to

physician

immune

system

functioning

in

presence

of

infection and is not

harmful

as

long as individual is not dehydrated or susceptible to febrile

seizures.

Fever

may

be

treated at home to

relieve

the

general discomfort

and

lethargy associated fever.

with

Fever

is

reportable, however, especially if it is unresponsive antipyretics

to and

fluids, because it often accompanies treatable tion

(viral

a

infecor

bacterial) 4. Adequate

fluid

intake needs to replace fluids lost through perspira-

19

4. Discuss

tion

importance

of

adequate intake

fluid at

all

and

respiration and to avoid dehydration

times and ways to

improve

hydration status when ill or when under

stress

(e.g.,

exercise,

5. Heat injuries can

be

immediately

hot

life-threatening.

environment).

Being aware of

5. Instruct families/

caregivers young

(of

children,

environ-mental hazards hydration

and levels

persons who are

can save one’s

outdoors in very

life

hot

climate)

dangers of heat ex-haustion and heat-stroke and ways to manage hot

envi-

ronments. Instruct parents to avoid leaving young in

chil-dren

unattended 6. Enable client or

car 6. Teach client or caregiver

to

promote cooling by means of:

caregiver

to

promote cooling.

20

a. Limiting

a. Encourage

heat

clothing/dress in

loss by radiation

lightweight,

and conduction

loose-fitting clothes. b. Cool

the

environ-ment with

air

conditioning

or

fans

b. Promotes

heat

loss

by

convection

c. Provide

cool/tepid sponge baths or immersion if

c. Heat loss by eva-

temperature is

poration and con-

>1040F or local

duction. Note: in

ice packs,

pediatric clients,

especially in

tepid

groin and axille

pre-ferred.

(areas of high

Alcohol

blood flow)

baths

water

is

sponge are

contraindicated because they increase peripheral vascular constrict-tion and CNS depression; cold-water sponges/ immersion

can

increase shivering, d. Keep clothing

producing heat.

21

and linens dry

d. To

1. Administer

shivering 1. To

medica-tions (e.g.,

reduce

dantro-

manage

hyper-thermia,

lene,

control shivering

chlorproma-zine,

and seizures.

or diazepam) as ordered

4

Demonstrate

un-

derstanding

in

avoid altered nutrition; risk for less than body requirements. As evidence by: a. Client/

caregiver verbalizing understandi ng how to keep adequate nutrition intake for client b. Client finished all of his meal c. Present weight in control

1. Assess

1. Identifies

client/care-

teaching

giver

and/or

knowledge

of

nutritional

needs helps

guide choice of intervention.

needs

and

ways client is meeting these needs.

2. Increase appetite

2. Teach

can increase the

client/caregiver way to in-

nutrition intake. a. To

promote

crease

sense of control

appetite:

and give client

a. Determine when

client

prefers/

opportunity to eat when

feeling

tolerates largest

more rested, less

meal of the day.

pain or nausea

flexi-

b. Reduce feeling of

bility in timing of

fullness that can

food intake

accompany

Maintain

b. Provide

nume-

rous small feed-

larger meals, and to

improve

22

ings, as indica-

chances

ted; supplement

increasing

with

amount of nutri-

easily

di-

gested snack

of the

ents taken over 24-hour period c. Enhance

food

satisfaction

and

stimulate appetite. c. Encourage

riety

in

choice,

vafood

varying

textures

and

taste sensations (e.g. sweet, salty,

fresh,

me-

1. To

enhance

thods of cook-

intake,

ing)

nutrients

(e.g.,

protein,

vita-

1. Suggest

client/caregiver

specific

mins) are needed to

to help recovery

increase

from

specific

against infection

illness

or

nutrients (e.g., protein, carbohydrates,

fats

and

calories),

as

need-ed,

2. Fluid is essential

providing client

to the digestive

with preferred

process and is

food

often taken with

and

seasoning

meals.

choices where

may need to be

Fluids

23

possible

withheld

2. Suggest

meals

client/caregiver

to

promote adequate/timel

before or

with

meals

if

interfering

with

food intake

y fluid intake

5

Client/caregiver

1. Expectation of

1. Discuss family

Demonstrate

perceptions of

effective family

situation

client and family members may/may not be

coping

realistic and may

Outcome criteria: a. Client/ family

interfere with 2. Identify current be-

can verbalize

haviors

the way to cope

family

members

the situation

(e.g.,

ig-noring/

b. Family/parents verbalizing their understanding of growth process in toddler

caring

of

the

client

at

home; anger and ways of touching between members,

family care

expressions) 3. Suggest family to

ability to deal with situation 2. Indicators

of

extent

of

problems existing with-in

family.

Relation-ships among

family

members before and after current new born affect ability

to

deal

involve client in

with problems of

taking care of the

caretaking

new baby

3. Getting involve in

24

taking care of the new baby help client to find his 4. Suggest family to

new role in

give the same

family as a

attention and care

brother and also

to both client and

feels posses

the new baby

4. Same attention and care help to

5. Explain family

avoid jealousy

about toddler growth

5. Helping family/ 6. Explain family/ pa-

rents

about

the

importance

of

deve-loping

good

com-munication between

parents

and child

parents to take care of client appropriate to client growth. 6. Good communication make it easier for family to teach client skill that is appropriate to his growth using potty)

C. IMPLEMENTING

Nursing diagnosis

Implementation

Respond

(e.g.,

25

1. Ineffective

1. Monitoring

air-way

respiratory

clearance

status;

related to re-

depth

1. Respiration

rate,

Difficulty

in

because of nasal

edema

of

minute.

respiration

tained secret and

35x/

rate

congestion

nasal

clear

mucous

with

discharge.

Client has runny nose 2. RR:

2. Monitoring

vital

sign

35x/minute,

pulse: 100x/minute, temperature: 1020 F 3. Clear

from nasal. Client

3. Evaluating

amount and type of

secretions

being produce.

cannot expel the secretion 4. Client’s

4. Assessing

client/care-giver of

contributing

parents that

they

really

concern

about

client

condition and don’t know

about

the

medication

causes, treatment

by

coughing it up said

knowledge

discharge

plan,

specific medication

and

therapeutic

5. Client’s

procedures

said

parents that

they

26

5. informing

understand

and

client/care-giver

will

the

to

suggestion

positioning

client’s

follow

head

appro-priate

for

age

and

6. Client’s

parents

condition/

said

that

they

disorder

understand

and

will

the

6. informing client or

caregiver

to

follow

suggestion 7. Client

maintain adequate

fluid

intake especially

is

given

Oxyme-tazolone 2 drops twice a day

warm fluid. 7. Administering 8. Client’s

pres-cribed

parents

expectorant, de-

said

that

they

congestant

understand

and

or

will maintain their

anti histamine

child to follow the

8. Discussing

important

of

therapeutic

following

the

procedure

procedure as it

9. Client’s

said

scheduled

parents that

they

understand

of

information

that

has given. 9. Informing

client/care-giver the

medication procedure

it

scheduled

therapeutic

about

as

(e.g.,

27

the

use

medicine,

of side

effect, schedule, dosage) 1. Acute

pain

re-lated

to

1. Noting

client’s

years old

age/

incre-asing of

developmental

pres-sure

level and current

middle

in ear

condition

(e.g.,

secondary to

infant/

child,

infection

critically ill)

process

1. Client at age of 2.5

2. Noting

2. From

physical

examination

possible

revealed tympanic

pa-

membrane red and

thophysiological/

bulging bilaterally.

psy-chological

Client

causes

of

bilateral

(e.g.,

inflame-

media

mation,

trauma,

pediatrician

pain

infection process)

3. Client

diagnosed otitis by seems

irritable, pulling at ears, and crying.

3. Observing

nonverbal

cues

(e.g., how client walks, body,

holds guarding

behaviors, grimacing facial, narrowed

focus;

crying, lethargy in infant)

4. RR:

35x/minute,

pulse 100x/minute, temperature 1020F

28

4. Monitor

vital

signs

during

episodes of pain 5. Administering

anal-gesic

5. Client

is

given

para-cetamol

250

mg

and

t.d.s

amoxicillin 250 mg to

t.d.s for 10 days.

maximal dosage as

“accep-table”

level of pain and inform client or caregiver the

about

medication

procedure

and

antibiotics to cure 6. Client’s

the infection

parents

can mention some

6. Teaching

caregiver to note

kind of cues of

the cues of pain

pain and the way

and to manage

to manage comfort

comfort for client

for client to reduce pain 7. Client’s

7. Teaching client or

parents

under-stand

and

caregiver to helps

know how to helps

client

their

child

to

demonstrate way

demonstrate

the

to maintain same

way

pressure in ear

same pressure in

(e.g.,

ear.

promote

swallowing

to

maintain

or

yawning)

1. Noting

1. Client at age of 2.5

29

1. Hyperthermia

re-lated

to

Increae

chronological

and

years

old.

His

developmental age

mother said that

of client

he

has

been

metabolism

feverish since last

secondary to

night

disease/infec tion process

2. Monitoring

core

tem-perature

by

2. Temperature

1020F

appropri-ate route 3. Teaching

how

parents

to

measure

3. Client’s

parents

child’s temperature,

can

at

body

how to measure

temperature to give

child’s temperature

antipyretic

medi-

and

cations, and what

the

symptoms to report

need

to physician

medi-cation

what

demonstrate

know

temperature

what 4. Discussing of

adequate

fluid

intake at all times and

ways

improve

antipyretic

to

hydration

to

reported 4. Client’s

ex-press

when under stress

adequate

(e.g., exercise, hot

intake

caregivers young

(of children,

persons who are outdoors

in

very

to parents the

understand-ding of importance

5. Informing families/

be

physician

status when ill or

environment).

and

symptoms

need

importance

when

of fluid

30

hot

climate)

dangers

5. Client’s

parents

heat

said

exhaustion

and

understand of the

heat-stroke

and

information

ways

of

in

to

manage

that

they that

has given

hot envi-ronments. Instructing parents to

avoid

leaving

young children in unattended car 6. Teaching client or

caregiver

to

promote cooling by means of: a. Limiting clothing/dress in lightweight,

b. Cooling the envi-

ronment with air or

fans c. Providing

cool/tepid sponge or

immersion

if

tempe-rature

is

>1040F or local ice

packs,

especially

in

groin and axillae (areas

of

express knowledge

clothes.

baths

parents

understanding and

loose-fitting

conditioning

6. Client’s

high

in

promoting cooling for their child

31

blood flow) 1. Altered

1. Assessing

1. Client’s

nutrition: Risk

client/care-giver

for less than

knowledge

of

really

body

nutritional needs

about

and ways client is

nutrition and know

meeting

that

re-

quirement relat-ed

to

decreased

said

parents

these

needs.

that

they

concern their their

need

child

adequate

appetite and

nutri-tion

the increased

growth

meta-bolism

development

second-dary to

process

for

said 2. Teaching

his and

2. Client’s

disease

child

parents that

they

understand

and

client/care-giver

will try to do some

ways to increase

ways to increase

appetite:

their

a. Determining

when

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

snack c. Encouraging varie-

ty in food choice, varying

textures

appetite

child’s

32

and taste sensetions (e.g., sweet, salty,

fresh,

me-

thods of cooking) 1. Suggest

client/care-giver to increase specific

nutrients

(e.g.,

protein,

carbohydrates, fats and calories), as

needed,

providing

client

with

preferred

food

and

parents

verbalizing

where

possible

their

understanding and willingness

seasoning choices

3. Client’s

to

provide

more

specific

nutrients

for their child.

2. Suggest

client/care-giver to

promote

adequate/ timely fluid intake

4. Client’s verbalizing

their willingness to promote adequate/ timely fluid intake for their child 5. Family coping;

1. Discussing family

risk

perceptions of

1. Client’s family said that

they

really

33

for

growth

situation

concern of client

related to sib-

growth

ling complex;

this situation can

the

affect

arrival family

new in

2. Identify current

behaviors of the family members (e.g., ignoring/ caring client at home; anger and ways of touching between family members, care expressions) 3. Suggest family to

and in

that client

growth 2. Client’s

mother

said that indeed, after the new born, she

spent

more

time to take care of the new baby than to client. But his husband has been extra attentive to client

involve client in taking care of the new baby

3. Client’s family said that involve

they

will

client

in

taking care of the 4. Suggest family to give the same

new baby 4. Client’s family said

attention and care to

that they will give

both client and the

the same attention

new baby

and care to both client and the new baby especially for client’s mother 5. Family understand

5. Explain family about toddler growth

about

toddler

growth 6. Family understand

6. Explain family/

and will develop

34

parents about the

good

importance of

communication

developing good

with their child

communication between parents and child

C. EVALUATION Nursing Diagnosis 1

Evaluation

S: –

Client’s parents said that they understand and will 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

35

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: – 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:

36

– 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 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

37

A : Goal meet P : Intervention stopped