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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 (130915.198)
AGNES ANITA P. (130915.174)
ANSALMUS ORON (130915.233)
WIWIN NURMALANTIKA (130915.234)
MEI D F DAEL (130915.161)
OLIVIA YOSEFINA A. (130915.163)
SAKTI RAHAYU (130915.180)
LISA HANDAYANI (130915.183)
RUFINA HURAI (130915.184)
FREDDI RAMANDA D. (130915.199)
MUHAMMAD HARIYADI (130915.206)
ILMASARI (130915.210)
META KAMELUH I.R. (130915.204)
RUDI HARIYONO (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
4

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.
5

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 : 750 cc/day
Problem : None

– B5: BOWEL (Gastrointestinal System)


Mouth : Pharynx slightly red, Stomatitis(+)
Complain : Abdomen(-),Alvi elimination(-).
Weight : 13 kg High : 100 cm
Nutrition : Eat 2x/day Portion : 3-5 spoon (half of
portion)
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 PROBLEMS

Subjective Data Increase metabolism Hypertermia


secondary to disease/
Client’s mother
infection process
said that he has
been 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 Acute pain

Client’s mother
said that Billy
tension in medial ear
has been irritable
and feverish
9

since last night

Objective press the tympanic


membrane
Client’s seems
irri-table, crying
Pulling at ears
tympanic membrane
tympanic
bulging bilaterally
membranes red
and bulging
bilaterally
Pain

Subjective: Less appetite and Altered nutrition: Risk


increased metabolism for less than body
Client’s mother
secondary to disease requirements
said that his
process
appetite and fluid
intake have
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 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 Sibling complex; The Family coping: risk for


new arrival in family growth
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 started
to refuse using
potty
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

Expected
Dx Nursing Orders Rationale
Outcomes

Demonstrate 1. Monitoring 1. Tachypnea is


12

1 adequate air respiratory usually present


exchange, as status; rate, to some degree
evidence by: depth and may be
a. Use of pronounced
correct during respiratory
breathing/co stress.
ughing 2. Inadequate
2. Monitoring vital
technique oxygenation
sign
cause increased
b. Productive pulse rate.
cough 3. Excessive and/or
3. Evaluate amount
sticky mucus can
and type of
make it difficult to
c. Client’s and secre-tions
maintain effective
care giver being pro-duce
airways
know and 4. To determine
understand aduca-tional
4. Assess client’s/
how to help needs
client to caregiver know-

maintain ledge of contri-

patent buting causes,

airway. treatment plan,


specific medica-
tion and thera-
peutic
procedures
5. inform client/
caregiver to
posi-tionning 5. Repositioning
client’s head head may, at
appropriate for times, be all that
age and is needed to
condition/ open or maintain
disorder open airway in
13

at-rest or
compromised
individual, such
6. inform client or as one with sleep
care giver to apnea
maintain 6. Cold water or
adequate fluid fluid can lower
intake especially the verge limit of
warm fluid. allergic and
7. Administer make nasal
prescribed congestion worse
expectorant,
decongestant or 7. Expectorant
anti histamine helps loosen
secretions so
they can be
coughed up an
wxpelled.
Decongestant
and or anti
histamine can
8. Discuss
helps reduce
important of
mucous edema
following the
and nasal
therapeu-tic
congestion
procedure as its
8. Discipline in
schedule
following the
9. Inform client/
therapeutic
caregiver about
procedure deter-
the medication
mine the success
procedure (e.g.,
of therapy
the use of
9. Knowledge about
medicine, side
medication can
effect, schedule,
14

dosage) increase
client/care-giver
discipline, avoid
anxiety related to
side effect of
medicine and
also determine
the success of
therapy

2 Demonstrate a 1. Note client’s 1. affecting ability to


decrease in age/ report pain
symptoms/ developmental parameters
complaints as note level and
in defining current
characteristic condition (e.g.,
a. Demonstrat infant/child,
e of critically ill)
relaxation 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 helps to
infection
plan the suitable
process)
way to relieve
4. Use pain rating
pain
scale
appropriate for
age/ cognition
(e.g., facial
expression/Wo
ng-Baker faces
pain scale for
pediatric or
nonverbal,
5. identify behaviors
behavior pain
that may indicate
scale)
pain in persons
5. Observe
who cannot
nonverbal
communicate
cues (e.g.,
verbally. Helpful
how client
in recognizing
walks, holds
presence of pain
body, guarding
behaviors, gri-
macing facial,
narrowed
6. Blood pressure,
focus; crying,
respiratory and
lethargy in
heart rate are
infant)
usually altered in
6. Monitor vital
acute pain
signs during
7. The type of
episodes of
medication
pain
ordered depends
16

on the type and


severity of pain.
7. Administer
Knowledge of
analgesic to
medication
maximal
procedure
dosage as
increase client/
“acceptable”
caregiver
level of pain
cooperation in
and inform
therapy.
client or
8. For client who
caregiver
cannot
about the
verbalizing pain,
medication
the caregiver
procedure
should note the
8. Teach
cues of pain to
caregiver to
start manage
note the cues
comfort to reduce
of pain and to
pain and helps
manage
client to maintain
comfort for
positive coping
client
against pain
9. Some way (e.g.,
swallowing,
yawning) can
cause opening
eustachius tube
that make the
9. Teach client or same pressure in
care-giver to ear, reduce
helps client bulging and pain.
demonstrate
way to
maintain same
17

pressure in ear
(e.g., promote
swallowing or
yawning)

3 Temperature in 1. Note 1. Infants, young


normal range as chronological chil-dren and
evidence by: and elderly persons
a. Maintain developmental are most
core age of client susceptible 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 in
normotherm infants and
ia young children
c. Client and than in older
care-giver children and
understand adults
and able to 2. To gain valid
mention data about the
2. Monitor core
ways to presence of
tem-perature by
promote temperature
appro-priate
normotherm elevation
route
ia (>98.6ºF [37ºC])
or fever (100.4ºF
[38ºC]).
3. Low grade fever
18

enhances
immune system
3. Teach parents
functioning in
how to measure
presence of
child’s
infection and is
temperature, at
not harmful as
what body
long as individual
tempe-rature to
is not dehydrated
give antipyretic
or susceptible to
medica-tions,
febrile seizures.
and what
Fever may be
symptoms to
treated at home
report to
to relieve the
physician
general
discomfort and
lethargy
associated with
fever. Fever is
reportable,
however,
especially if it is
unresponsive to
antipyretics and
fluids, because it
often
accompanies a
treatable infec-
tion (viral or
bacterial)
4. Adequate fluid
intake needs to
replace fluids lost
through perspira-
19

4. Discuss tion and


importance of respiration and to
adequate fluid avoid
intake at all dehydration
times and ways
to improve
hydration status
when ill or when
under stress 5. Heat injuries can
(e.g., exercise, be immediately
hot life-threatening.
environment). Being aware of
5. Instruct families/ environ-mental
caregivers (of hazards and
young children, hydration 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 chil-dren
in unattended
car 6. Enable client or
6. Teach client or caregiver to
caregiver to promote cooling.
promote cooling
by means of:
20

a. Limiting a. Encourage heat


clothing/dress in loss by radiation
lightweight, and conduction
loose-fitting
clothes.
b. Cool the
environ-ment
b. Promotes heat
with air
loss by
conditioning or
convection
fans
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 water is
groin and axille pre-ferred.
(areas of high Alcohol sponge
blood flow) baths are
contraindicated
because they in-
crease 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 reduce


1. Administer shivering
medica-tions 1. To manage
(e.g., dantro- hyper-thermia,
lene, control shivering
chlorproma-zine, and seizures.
or diazepam) as
ordered

4 Demonstrate un-
1. Assess 1. Identifies
derstanding in
client/care- teaching needs
avoid altered nutri-
giver and/or helps
tion; risk for less
knowledge of guide choice of
than body require-
nutritional intervention.
ments. As eviden-
needs and
ce by:
ways client is
a. Client/
meeting these
caregiver
needs. 2. Increase appetite
verbalizing
2. Teach can increase the
understandi
client/care- nutrition intake.
ng how to
giver way to in- a. To promote
keep
crease sense of control
adequate
appetite: and give client
nutrition
a. Determine when opportunity to eat
intake for
client prefers/ when feeling
client
tolerates largest more rested, less
b. Client
meal of the day. pain or nausea
finished all
Maintain flexi- b. Reduce feeling of
of his meal
bility in timing of fullness that can
c. Present
food intake accompany
weight in
b. Provide nume- larger meals, and
control
rous small feed- to improve
22

ings, as indica- chances of


ted; supplement increasing the
with easily di- amount of nutri-
gested snack ents taken over
24-hour period
c. Enhance food
satisfaction and
stimulate
appetite.
c. Encourage va-
riety in food
choice, varying
textures and
taste sensations
(e.g. sweet, sal-
ty, fresh, me- 1. To enhance
thods of cook- intake, specific
ing) nutrients (e.g.,
1. Suggest protein, vita-
client/care- mins) are needed
giver to to help recovery
increase from illness or
specific against infection
nutrients (e.g.,
protein, carbo-
hydrates, fats
and calories),
as need-ed, 2. Fluid is essential
providing client to the digestive
with preferred process and is
food and often taken with
seasoning meals. Fluids
choices where may need to be
23

possible
withheld before
2. Suggest
meals or with
client/care-
meals if
giver to
interfering with
promote
food intake
adequate/timel
y fluid intake

5 1. Expectation of
Client/caregiver 1. Discuss family
client and family
Demonstrate perceptions of
members
effective family situation
may/may not be
coping
realistic and may
Outcome criteria: interfere with
ability to deal
a. Client/ family 2. Identify current be-
with situation
can verbalize haviors of the
2. Indicators of
the way to cope family members
extent of
the situation (e.g., ig-noring/
problems existing
caring client at
b. Family/parents with-in family.
home; anger and
verbalizing their Relation-ships
ways of touching
understanding among family
between family
of growth members before
members, care
process in and after current
expressions)
toddler new born affect
3. Suggest family to 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/
parents to take
6. Explain family/ pa-
care of client
rents about the
appropriate to
importance of
client growth.
deve-loping good
6. Good
com-munication
communication
between parents
make it easier for
and child
family to teach
client skill that is
appropriate to his
growth (e.g.,
using potty)

C. IMPLEMENTING

Nursing diagnosis Implementation Respond


25

1. Ineffective 1. Monitoring
1. Respiration rate
air-way respiratory
35x/ minute.
clearance status; rate,
Difficulty in
related to re- depth
respiration
tained secret
because of nasal
and edema
congestion with
of nasal
clear discharge.
mucous
Client has runny
nose
2. RR: 35x/minute,
2. Monitoring vital pulse:
sign 100x/minute,
temperature: 1020
F
3. Clear discharge
from nasal. Client
3. Evaluating
cannot expel the
amount and type
secretion by
of secretions
coughing it up
being produce.
4. Client’s parents
said that they
really concern
4. Assessing
about client
client/care-giver
condition and don’t
knowledge of
know about the
contributing
medication
causes,
treatment plan,
specific
medication and
therapeutic 5. Client’s parents
procedures said that they
26

5. informing understand and


client/care-giver will follow the
to positioning suggestion
client’s head
appro-priate for
age and 6. Client’s parents
condition/ said that they
disorder understand and
6. informing client or will follow the
caregiver to suggestion
maintain 7. Client is given
adequate fluid Oxyme-tazolone 2
intake especially drops twice a day
warm fluid.
7. Administering
pres-cribed 8. Client’s parents
expectorant, de- said that they
congestant or understand and
anti histamine will maintain their
8. Discussing child to follow the
important of therapeutic
following the procedure as it
therapeutic scheduled
procedure as it 9. Client’s parents
scheduled said that they
understand of
information that
has given.

9. Informing
client/care-giver
about the
medication
procedure (e.g.,
27

the use of
medicine, side
effect, schedule,
dosage)

1. Acute pain 1. Noting client’s 1. Client at age of 2.5


re-lated to age/ years old
incre-asing of developmental
pres-sure in level and current
middle ear condition (e.g.,
secondary to infant/ child, 2. From physical
infection critically ill) examination
process 2. Noting possible revealed tympanic
pa- membrane red and
thophysiological/ bulging bilaterally.
psy-chological Client diagnosed
causes of pain bilateral otitis
(e.g., inflame- media by
mation, trauma, pediatrician
infection process) 3. Client seems
irritable, pulling at
ears, and crying.

3. Observing
nonverbal cues
(e.g., how client
walks, holds
body, guarding
behaviors,
grimacing facial,
4. RR: 35x/minute,
narrowed focus;
pulse 100x/minute,
crying, lethargy in
temperature 1020F
infant)
28

4. Monitor vital 5. Client is given


signs during para-cetamol 250
episodes of pain mg t.d.s and
5. Administering amoxicillin 250 mg
anal-gesic to t.d.s for 10 days.
maximal dosage
as “accep-table”
level of pain and
inform client or
caregiver about
the medication
procedure and
antibiotics to cure
the infection 6. Client’s parents
6. Teaching can mention some
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 parents
7. Teaching client or under-stand and
caregiver to helps know how to helps
client their child to
demonstrate way demonstrate the
to maintain same way to maintain
pressure in ear same pressure in
(e.g., promote ear.
swallowing or
yawning)

1. Noting 1. Client at age of 2.5


29

1. Hyperthermia chronological and years old. His


re-lated to developmental age mother said that
Increae of client he has been
metabolism feverish since last
secondary to night
disease/infec 2. Monitoring core 2. Temperature
tion process tem-perature by 1020F
appropri-ate route
3. Teaching parents
how to measure 3. Client’s parents
child’s temperature, can demonstrate
at what body how to measure
temperature to give child’s temperature
antipyretic medi- and know when
cations, and what the temperature
symptoms to report need antipyretic
to physician medi-cation and
what symptoms
4. Discussing need to be
importance of reported to
adequate fluid physician
intake at all times 4. Client’s parents
and ways to ex-press the
improve hydration understand-ding of
status when ill or importance of
when under stress adequate fluid
(e.g., exercise, hot intake
environment).
5. Informing families/
caregivers (of
young children,
persons who are
outdoors in very
30

hot climate) in 5. Client’s parents


dangers of heat said that they
exhaustion and understand of the
heat-stroke and information that
ways to manage 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
6. Client’s parents
clothing/dress in
express
lightweight,
understanding and
loose-fitting
knowledge in
clothes.
promoting cooling
b. Cooling the envi-
for their child
ronment with air
conditioning or
fans
c. Providing
cool/tepid sponge
baths or
immersion if
tempe-rature is
>1040F or local
ice packs,
especially in
groin and axillae
(areas of high
31

blood flow)

1. Altered 1. Assessing 1. Client’s parents


nutrition: Risk client/care-giver said that they
for less than knowledge of really concern
body re- nutritional needs about their child
quirement and ways client is nutrition and know
relat-ed to meeting these that their child
decreased needs. need adequate
appetite and nutri-tion for his
the increased growth and
meta-bolism development
second-dary 2. Client’s parents
to disease said that they
process 2. Teaching understand and
client/care-giver will try to do some
ways to increase ways to increase
appetite: their child’s
a. Determining when appetite
client prefers/ tole-
rates largest meal
of the day. Maintain
flexibility in timing
of food intake
b. Providing nume-
rous small feed-
ings, as indicated;
supplements with
easily digested
snack
c. Encouraging varie-
ty in food choice,
varying textures
32

and taste sense-


tions (e.g., sweet,
salty, fresh, me-
thods of cooking)
1. Suggest
client/care-giver
to increase spe-
cific nutrients
(e.g., protein,
carbohydrates,
fats and calories),
as needed,
providing client 3. Client’s parents
with preferred verbalizing their
food and understanding and
seasoning willingness to
choices where provide more
possible specific nutrients
2. Suggest for their child.
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 1. Discussing family 1. Client’s family said


coping; risk perceptions of that they really
33

for growth situation concern of client


related to sib- growth and that
ling complex; this situation can
the new affect in client
arrival in growth
2. Identify current
family 2. Client’s mother
behaviors of the
said that indeed,
family members (e.g.,
after the new born,
ignoring/ caring client
she spent more
at home; anger and
time to take care of
ways of touching
the new baby than
between family
to client. But his
members, care
husband has been
expressions)
extra attentive to
3. Suggest family to client
involve client in
taking care of the 3. Client’s family said
new baby that they will
involve client in
taking care of the
4. Suggest family to new baby
give the same 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 about toddler

toddler growth 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
Evaluation
Diagnosis

1
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 com-
munication 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

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