Care Plan Help

Neonatal Hyperbilirubinemia Fluid Volume Deficit r/t diarrhea, fluid intake, and/or phototherapy

Goals: Body fluids of the neonate will be accurate for weight, height, and age

Interventions:

Maintain strict intake and output Administer fluid or water in between feedings Record amount/quality of stools Asses skin turgor/ sunken fontanels

Impaired Skin Integrity r/t Hyperbilirubinemia and phototherapy

Goals: Infant skin integrity will be maintained

Interventions:

Assess skin every 6 hours monitor direct and indirect bilirubin keep skin clean and moisturized massage reddened areas/areas that stand out

Hyperthermia r/t phototherapy

Goals: Infants temperature will stay within 35.5- 37.2 degrees Celsius

Interventions:

Obtain vital signs every 2 hours Keep room at a neutral ambient temperature

OverdoseRisk for injury (hepatic/renal toxicity) r/t adverse effects of drug overdose

Goals: Patient will remain free of signs of hepatic or renal toxicity.

Patient pertinent lab values (acetaminophen, liver enzymes, creatinine, PT ,etc.) will remain within normal values.

Interventions:

Obtain blood collection for ordered lab values Monitor renal function tests and strict Intake and Output Perform neurologic exam as indicated by healthcare provider Obtain vital signs every 2 hours

Ineffective impulse control r/t suicidal feeling

Goals: Patient will remain free from harm

Cooperate with behavioral modification plan

Interventions:

Ensure that a sitter is present with patient at all times following protocol of orders Refer to mental health treatment and communicate with Stress Center if indicated

Risk for suicide r/t previous suicide attempt

Goals: Patient will obtain no access to harmful objects

Patient will meet with/be assessed by a psychologist of other Stress Center related physician as indicated

Patient will discuss/disclose suicidal thoughts with a staff member if suicidal ideation is present

Interventions:

Develop a positive, therapeutic relationship with patient; do not make promises that can’t be kept

Refer for mental health counseling Call for a sitter and do not leave the patient alone while hospitalized

CardiacTetralogy of Fallot, Transposition of the Great Arteries, Atrial/Ventricular Septal Defect, Patent Ductus Arteriosus, Aortic/Pulmonic Stenosis

Impaired gas exchange r/t altered pulmonary blood flow secondary to congenital heart disease

Goals: Patient will remain free of signs of respiratory distress (including hypoxia, nasal flaring, intercostal retractions, grunting, etc.)

Parents/care providers will be able to verbalize signs and symptoms of hypoxia, tet. spells, and any respiratory distress relevant to child’s illness

Interventions:

Monitor respiratory rate, depth, and ease of respiration every 2 hours Monitor continual oxygen saturation by pulse oximetry Educate care providers on signs of respiratory distress and answer any questions

Altered Cardiac Output r/t ineffective circulation secondary to specific anatomic defect

Goals: Patient will show adequate cardiac output as evidenced by blood pressure, heart rate, and rhythm within normal values appropriate to illness.

Patient’s urine output will be 1-2 ml/kg/hour

Interventions:

Monitor for signs of decreased cardiac output such as fatigue, dyspnea, edema, etc.

Monitor orthostatic blood pressure and daily weights Administer oxygen as needed per orders Give knee-chest position during tet. spells Provide restful environment by clustering care and minimizing unnecessary

disturbances

Imbalanced Nutrition: less than body requirements r/t excessive energy demands required by increased cardiac workload

Goals: Patient will progressively gain weight as expected/ to desired goal.

Patient will consume adequate nutrition, including being given supplements if indicated.

Interventions:

Obtain daily weights Monitor and document food intake including types and amount of foods

eaten/beverages drank. Call physician if child is not gaining weight or shows symptoms of malnutrition.

OncologyFever/NeutropeniaRisk for infection r/t immunosuppression, invasive procedures, malnutrition, or pharmaceutical agents

Goals: Patient will remain free from symptoms of infection

Patient will maintain white blood cell count and differential within normal limits.

Interventions:

Promote good hand washing procedures by both staff and visitors, by educating on the importance.

Monitor temperature and vitals every 2 hours. Monitor CBC with differential WBC and other related lab values. Obtain cultures as indicated.

Risk for impaired oral mucous membrane r/t immunosuppression

Goals: Patient will maintain moist, intact oral mucous membranes that are free of ulceration, inflammation, infection, and debris.

Intervention:

Inspect oral cavity at least once per day. If indicated, encourage patient to brush teeth with soft toothbrush at least twice

per day. Encourage patient to use mouth wash as ordered.

Chemotherapy AdministrationNausea r/t chemotherapy administration

Goals: Patient will verbalize any nauseous feelings as they arise.

Patient will state relief of nausea after an intervention has been completed.

Interventions:

Administer an anti-emetic prior to and after chemotherapy administration start, as ordered.

Document each episode of nausea and/or vomiting separately, as well as effectiveness of interventions.

Ineffective individual coping r/t situational crisis

Goals: Patient will demonstrate normal adaptive coping methods.

Patient will show facial expressions, gestures, and activity levels that reflect decreased distress within 30 minutes of chemotherapy administration.

Interventions:

Encourage drawing or other therapeutic play for expression of feelings. Discuss how to behave during treatments.

Fatigue r/t lack of sleep privacy/control

Goals: Patient will sleep for enough hours appropriate to their age.

Patient will state, if able, feeling rested.

Interventions:

Cluster care as much as possible to avoid unnecessary interruptions during normal rest and sleep times.

Alter patient’s room to allow designated periods of rest

AppendectomyAcute Pain r/t distension of intestinal tissues by inflammation, surgical procedure

Goals: Patient will state a decreased pain score after intervention has been completed (or if unable to speak, will show signs of decreased pain such as decreased HR, BP, and facial expressions.)

Patient will state/demonstrate the ability to obtain sufficient amounts of sleep and rest.

Interventions:

Explain pain management plan with patient or with family if patient is unable to understand.

Assess pain intensity (by 0-10 verbal statement or symptoms of pain- facial grimace, position, vitals) every 4 hours and again before and after an intervention is completed.

Administer pain medication as ordered. Offer non-pharmacological treatments for pain such as hot/cold packs, relaxation

techniques/deep breathing, aroma therapy, music therapy, etc.

Risk for fluid volume Deficit r/t NPO post. operative, hypermetabolic state (fever, healing process)

Goals: Patient will maintain blood pressure, pulse and body temperature within their normal limits.

Patient will maintain urine output of 1-2 ml/kg/hour.

Interventions:

Monitor strict input and output. Obtain daily weights. Monitor vital signs every 4 hours. Administer fluids as ordered, and encourage fluids with and between meals.

Risk for infection r/t appendicitis perforation of the appendix, peritonitis, abscess formation, surgical incision

Goals: Patient will remain free from signs of infection.

Patient will achieve timely wound healing within acceptable time frame per surgeon.

Interventions:

Practice and educate on proper hand hygiene and aseptic wound care. Inspect incision and dressings, while noting characteristics of the wound such as

drainage, erythema, or inflammation. Monitor vital signs every 4 hours. Administer antibiotic as ordered.

HematologyFactor DeficiencyRisk for bleeding injury r/t weakness of the defense system secondary to hemophilia

Goals: Patient will have no bleeding injuries while hospitalized.

Interventions:

Create an environment that is safe and allows the regulatory process for the patient, and encourage parents to choose activities that are acceptable and safe.

Perform and document admission risk for falls. Monitor for signs of bleeding, including: bleeding gums, hematemesis, petechiae,

hematuria, and blood in the stool Provide factor VIII concentrates and blood products as ordered.

Sickle Cell CrisisAcute pain r/t sickle cell crisis.

Goals: Patient will state a decreased pain score after intervention has been completed (or if unable to speak, will show signs of decreased pain such as decreased HR, BP, and facial expressions.)

Patient will state/demonstrate the ability to obtain sufficient amounts of sleep and rest.

Interventions:

Explain pain management plan with patient or with family if patient is unable to understand.

Assess pain intensity (by 0-10 verbal statement or symptoms of pain- facial grimace, position, vitals) every 4 hours and again before and after an intervention is completed.

Administer pain medication as ordered. Offer non-pharmacological treatments for pain such as hot/cold packs, relaxation

techniques/deep breathing, aroma therapy, music therapy, etc.

Ineffective tissue perfusion r/t vaso-occlusive nature of sickling, inflammatory response

Goals: Patient will demonstrate adequate tissue perfusion, evidenced by stable vital signs and palpable peripheral pulses.

Interventions:

Monitor vital signs every 2 hours, paying attention to hypotension and increased or shallow respirations.

Assess skin for pallor, cyanosis, coolness, and delayed capillary refill.

RenalNephrotic Syndrome

Impaired urinary elimination r/t sodium and water retention

Goals: Patient will demonstrate voiding frequency appropriate to age (ml per kg/hr)

Patient will state absence of pain or increased urgency during elimination

Interventions:

Monitor strict Intake and Output Perform focus physical assessment, palpating the lower abdomen and checking

for bladder distension Perform straight catheterization if indicated to relieve bladder distension

Excess fluid volume r/t water retention and decreased oncotic pressure

Goals: Patient will maintain urine output of 0.5 mL/kg/hr or more.

Patient will maintain vitals signs within their normal limits.

Interventions:

Restrict fluid intake Monitor daily weight for sudden increases, and strict intake and output Encourage diet with low sodium and high protein Monitor serum albumin level and provide protein intake as appropriate

Risk for infection r/t decreased immune system secondary to loss of protein in urine

Goals: Patient will show no signs of infection while hospitalized.

Interventions:

Restrict visitors with colds to in order to protect the patient Wash hands thoroughly and encourage staff and visitors/family to do so as well. Monitor vital signs every 4 hours

Imbalanced nutrition: less than body requirements r/t disease process

Goals: Keep the patient at an appropriate weight for age and height.

Interventions:

Provide small, frequent meals that are low in sodium and high in protein and carbs

Provide nutritional supplementation as indicated Monitor daily weights for decrease

Ear, Nose, ThroatTonsillectomy/AdenoidectomyAcute pain r/t surgical procedure

Goal: Patient will report pain at an acceptable number for them (0-10 pain score) or, if unable to speak, will show no physiological signs of pain (facial grimaces, tachycardia, hypertension, etc)

Patient will obtain enough sleep/relax as appropriate for age

Interventions:

Pain will be assessed every 4 hours Pain medications will be administered as ordered, with pain level being

asked/observed both before and 30 minutes after medication intervention Patient will be offered non-pharmacological treatments for pain including heat/ice

packs, popsicles, musical therapy, changes in position, etc.

Risk for bleeding r/t surgical procedure

Goals: Patient will have no bleeding observed from the nose or mouth

Patient will show not show signs of excessive swallowing or frequent clearing of throat

Interventions:

Observe inside of mouth and nose for any indications of bleeding Obtain vital signs every 4 hours and monitor for irregular breathing patterns or

tachycardia

Risk for infection r/t factors of surgery

Goals: Patient will show no signs of infection, including being afebrile and vitals signs within appropriate limits for that patient

Interventions:

Vital signs and temperature will be taken every 4 hours Patient will be given prophylactic antibiotics as ordered Nurse will educate care providers on signs and symptoms to look for of infection

Cochlear Implant

Risk for infection r/t surgical procedure

Patient will show no signs of infection, including being afebrile and vitals signs within appropriate limits for that patient

Interventions:

Vital signs and temperature will be taken every 4 hours Patient will be given prophylactic antibiotics as ordered Nurse will educate care providers on signs and symptoms to look for of infection Nurse will monitor for any drainage coming from patient’s ear

Acute pain r/t surgical procedure

Goal: Patient will report pain at an acceptable number for them (0-10 pain score) or, if unable to speak, will show no physiological signs of pain (facial grimaces, pulling on ear, tachycardia, hypertension, etc.)

Patient will obtain enough sleep/relax as appropriate for age

Interventions:

Pain will be assessed every 4 hours Pain medications will be administered as ordered, with pain level being

asked/observed both before and 30 minutes after medication intervention Patient will be offered non-pharmacological treatments for pain including heat/ice

packs, popsicles, musical therapy, changes in position, etc.

Hospice

Ineffective family coping r/t prolonged disease/disability progression that exhausts the supportive capacity of significant persons

Goals: Family will be able to verbalize and express a realistic understanding and expectations of the patient

Family will be able to identify and verbalize resources available to them to help them cope

Interventions:

Assess level of anxiety present in the family Establish a trusting and caring rapport with the patient and family Provide family with relevant resources (brochures, verbal information, contact

info) Answer families questions as appropriate or contact the appropriate provider if

unable

Activity Intolerance r/t generalized weakness, pain, progressive disease state/ debilitating condition

Goals: Patient will obtain appropriate hours of sleep and rest for age and condition.

Patient will remain free of preventable discomfort and/or complications

Interventions:

Assess sleep patterns and note changes in emotional behaviors Recommend scheduling activities for the hours when the patient seems to have

the most energy; adjust activities as necessary Encourage patient to do whatever possible activities of daily living themselves Provide supplemental oxygen as indicated

Anticipatory grieving r/t anticipated loss of physiological well-being, perceived death of patient

Goals: Patient will identify and verbalize feelings, if capable.

Patient will accept assistance in meeting the needs of themselves and their family

Interventions:

Develop a trusting rapport with the patient/family by being kind and using therapeutic communication

Keep patient and family informed on physical care and support in symptom control, and inform about health care options at the end of life including palliative care, hospice care, and home care

Answer patients and families questions with honesty and kindness

Pain r/t progressive disease state/debilitating condition

Goals: If possible, patient will state that pain is relieved/controlled.

Patient will obtain enough sleep/relax as appropriate for age

Interventions:

Assess pain every 4 hours and before and after an intervention Follow pain management protocol; administer pain medications as appropriate Offer non-pharmacological treatments of pain Encourage patient and family to express feelings of concern regarding narcotic

use

Created by: Abby Bullerdick

Purdue University School of Nursing

Ackley, B,J., Ladwig, G.B. (2014).Nursing Diagnosis Handbook: An Evidenced Base Guide to Planning Care. Missouri: Mosby Elsevier.