Date/Time

Cues Need Nursing Diagnosis

with Rationale

Objectives/ Plan

Nursing Intervention with Rationale

Evaluation

AUGUST

3

2010

8am

Objective:

-temp 38.6 C RR 46 PR 136

-skin warm to touch

-pallor noted on the lips and skin

NUTRIONAL-METABOLIC

PATTERN

Hyperthermia related to release of endogenous pyrogens

Rationale: Fever results from an imbalance between the elimination and the production of heat. Infection, neurologic disease, malignancy, pernicious anemia, thromboembolic disease, paroxysomal tachycardia, congestive heart failure, crushing injury, severe trauma, and many drugs may cause fever. Fever is the effect of body’s response due to infection inside the body. ( Mosby’s pocket dictionary of medicine, nursing, and allied health 4th

edition)

Within the 4 hours span of care, patient’s temperature will go down to the normal range.

1. Monitor and record vital signs especially temperature® Monitoring the patient helps in the continuity of care. Vital signs are also essential to determine deviations from normal 2. Do tepid sponge bath to the client® TSB helps in decreasing the body temp.

3. Emphasize the importance of proper hygiene to the parents.® These reduce the risk of any incoming infection.

4. Encourage the parents to increase the Oral Fluid Intake of the client.® Helps in maintaining the adequate fluid in the body.

5. Promote surface cooling by means of undressing (heat loss by radiation and conduction); cool environment and/or fans (heat loss by convection).

6. Administer antipyretics as needed® Administering antipyretics helps in reducing the body temp.

7. Recheck the clients temperature® To determine the effect of the therapeutic and pharmacologic mgt provided.

8. Assess fluid loss and facilitates oral fluid intake or administer IV fluids to accomplish fluid replacement.

® Increase metabolic rate and diaphoresis associated with fever causing loss of body fluids.

Goal met

Within our 4 hours span of care, the patient’s temperature went down to 37.6 C which is a normal range.

Date/Time

Cues Need Nursing Diagnosis

with Rationale

Objectives/ Plan

Nursing Intervention with Rationale

Evaluation

AUGUST

2

2010

9am

Objective:- NGT at

right nare for feeding

- OTF of 2300 kcal/day- Wt:

15kg- Ht:

100cm

(A 5 year and 1 month old (male) child who is 34 pounds and is 3 feet and 3 inches tall has a body mass index of 15.7, which is at the 60th percentile, and would indicate that your child is at a

NUTRIONAL-METABOLIC

PATTERN

Risk for Imbalanced nutrition: Less than body requirements related to increased metabolic needs caused by disease process or therapy

After 4 hours span of care, the patients watcher will be able to verbalize and demonstrate understanding of the causative factors when known and necessary intervention.

Document actual weight; do not estimate.® Patients may be unaware of their actual weight or weight loss due to estimating weight.

Obtain nutritional history; include family, significant others, or caregiver in assessment.® Patient’s perception of actual intake may differ.

Monitor laboratory values that indicate nutritional well-being/deterioration.

Weigh patient weekly.® During aggressive nutritional support, patient can gain up to 0.5 pound/day.

Suggest ways to assist patient with meals as needed. Ensure a pleasant environment, facilitate proper position, and provide good oral hygiene and dentition.® Elevating the head of bed 30 degrees aids in swallowing and reduces risk of aspiration.

Monitor laboratory values, and report significant changes to physician. ®Laboratory values provide objective data regarding nutritional status.

Explain the importance of adequate nutrition and fluid intake to client’s watcher. ®Clients watcher may have inadequate or inaccurate knowledge regarding the contribution of good nutrition to overall wellness.

GOAL MET

After 4 hours span of care the patients watcher was able to verbalize understanding of the health teaching rendered.

healthy weight.)

Date/Time

Cues Need Nusring Diagnosis Objective of care Nursing Intervention Evaluation

AUGUST

2,2010

8am

Objective: With NGT

at right nare intact and patent

With ET tube attached to CPAP

Coughing noted

NUTRITIONAL-METABOLIC

PATTERN

Risk for aspiration related to presence of endotracheal tube

®Both acute and chronic conditions can place patients at risk for aspiration. Acute conditions, such as postanesthesia effects from surgery or diagnostic tests, occur predominantly in the acute care setting. Chronic conditions, including altered consciousness from head injury, spinal cord injury, neuromuscular weakness, hemiplegia and dysphagia from stroke, use of tube feedings for nutrition, endotracheal intubation, or mechanical ventilation may be encountered in the home, rehabilitative, or hospital settings. Elderly and

After 8 hours span of care, the patient will be able to experience no aspiration.

1. Auscultate lung sounds frequently.® Bronchial auscultation of lung sounds was shown to be specific in identifying clients at risk for aspiration. 2. Elevate client to the highest or best possible position for eating and drinking and during tube feedings.3. Provide information about the effects of aspiration on the lungs.® Severe coughing and cyanosis associated with eating or drinking or feeding indicates onset of respiratory symptoms associated with aspiration and requires immediate intervention.4. Record appearance, characteristics and duration of cough.5. Check placement of NGT before feeding.® A displaced tube may erroneously deliver tube feeding into the airway.6. Auscultate bowel sounds to evaluate bowel motility.® Decreased gastrointestinal motility increases the risk of aspiration because food or fluids accumulate in the stomach. 7. Keep suction setup available and use as needed.® This is necessary to maintain a patent airway.

After 8 hours span of care patient was free from aspiration.

GOAL MET.

cognitively impaired patients are at high risk. Aspiration is a common cause of death in comatose patients.

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=04

Date/Time

Cues Need Nursing Diagnosis

with Rationale

Objectives/ Plan Nursing Intervention with Rationale

Evaluation

AUGUST

2

2010

9am

Objective: On

endotracheal tube attached to CPAP with FiO2 100% @ 4Lpm

Crackles noted on both lungs upon auscultation

use of accessory muscles for respiration: elevated shoulders.

respiratory rate: RR-46cpm

Secretion characteristics: whitish in color

ACTIVITY-EXERCISE

PATTERN

Ineffective breathing patternrelated to decreased lung expansion

After 8 hours span of care the patient will be able to maintain respiratory rate at normal range.

Assess respiratory function, e.g., breath sounds, rate, and use of accessory muscles and secretion characteristics and amount.® Provides a basis for evaluating adequacy of ventilation

Position patient in semi- or high- Fowler’s position.® Positioning helps maximize lung expansion.

Assess airway patency.® Maintain adequate airway patency.

Note retractions or flaring of nostrils. ®These signify an increase in work of breathing.

Administer oxygen at lowest concentration indicated and prescribed respiratory medications.®For management of underlying pulmonary condition, respiratory distress or cyanosis.

Suction airway as needed.®This is to clear secretions.

Monitor pulse oximetry, as indicated.®verify maintenance/improvement in O2 saturation.

GOAL MET

After 8 hours span of care the patient was able to maintain his respiratory rate at normal level.