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Pediatric ICU
INSTRUCTIONS: For this case scenario, you will develop a Nursing Care Plan using SNL,
the Standardized Nursing Languages of NANDA, NOC and NIC (NNN). You will be
completing the blank nursing care plan that accompanies this scenario.
Patient is a 4-month-old boy who has been admitted to the PICU after being seen in the
ED with severe respiratory distress and dehydration.
Temperature = 39°, pulse = 200, RR = 68 and shallow.
He has poor response to NMT treatments x 2.
An ABG = O2 sat of 80, pH of 7.3, PO2 of 75, and CO2 of 50.
An IV is started and he is intubated.
His medical diagnosis is RSV pneumonitis, possible bacterial pneumonia, and respiratory
failure.
Functional Health Patterns
Nursing assessment data is organized in Functional Health Patterns. Functional Health Patterns can
help direct the choice of Nursing Diagnoses. The eleven functional health patterns are Health
Perception-Health Management; Cognitive-Perceptual; Nutritional-Metabolic; Elimination; Activity-
Exercise; Sleep/Rest; Self-Perception/Self-Concept; Role/Relationship; Sexuality/Reproductive;
Coping/Stress/Tolerance; and Value/Belief.
Ø Health Perception/Management:
Previously healthy infant with 2 day history of fever, cough, dyspnea &
vomiting.
Mother and both siblings have had colds.
On no medication at home.
Immunizations are up to date.
Ø Role/Relationship:
Patient is accompanied by his mother.
Patient lives with mother, age 18, 2 siblings ages 2 and 3, and maternal
grandmother.
Patient’s father is not involved in his care.
Patient’s mother appears concerned and states she did not realize that her
baby was so sick.
Ø Activity/Exercise:
Breath sounds are very coarse and congested. He has many secretions.
He is restless and agitated.
Ø Elimination:
No urine output for the last 8 hours.
No bowel movement for 2 days.
Activity-Exercise I
is the most affected functional health pattern for this patient.
NURSING DIAGNOSIS
Appropriate nursing diagnoses (NANDA) for this patient would include:
Gas exchange, impaired
Defining Characteristics:
Decreased PO2
Abnormal arterial pH
Irritability/restlessness
Abnormal rate, rhythm, depth of breathing
Related factors (Etiology):
RSV pneumonitis
Possible bacterial pneumonia
Hyperthermia
Defining Characteristics:
Increase in body temperature above normal range
Warm to touch
Increased respiratory rate
Related Factors (Etiology):
Atypical pneumonia
Dehydration
While all these nursing diagnoses are appropriate, for purposes of this exercise
let’s use:
Gas Exchange, Impaired.
On the nursing care plan form write in the nursing diagnosis and check the defining
characteristics and related factors (Etiology).
• The next step is to select nursing outcomes that can best affect this
nursing diagnosis.
• Listed below are two appropriate nursing outcomes for this patient.
Select ONE of the above listed nursing outcomes for this care plan exercise, go
to the nursing care plan and check the indicators that you think will best
measure your patient’s progress towards the outcome that you’ve chosen. You
will need to RATE you patient’s current status for each indicator.
Now that you have chosen your outcome for this patient, you will select the
interventions that will best meet this outcome.
The following two Nursing Interventions are appropriate for this patient. Review
the activities listed below each NIC and select 5 that apply. Write these five on
the nursing care plan in the activity column.
• Maintain patent IV access • Maintain patent airway • Monitor ABG & electrolyte
levels
• Monitor hemodynamic status • Position to facilitate adequate • Monitor for symptoms of
ventilation respiratory failure
• Monitor for respiratory • Monitor determinants of • Provide oxygen therapy
pattern tissue oxygen delivery
• Provide mechanical ventilatory • Monitor determination of • Obtain ordered specimen for
support oxygen consumption lab analysis of acid-base
balance
• Monitor for worsening • Reduce oxygen consumption • Monitor neurological status
electrolyte imbalance
• Provide frequent oral hygiene • Promote orientation • Monitor for loss of acid( e.g.
vomiting)
• Monitor for loss of • Administer prescribed alkaline • Instruct pt &/or family on
bicarbonate(e.g. fistula medications based on ABG actions instituted to treat the
drainage & diarrhea) results acid-base imbalance
The following two Nursing Interventions are appropriate for this patient. Review the
activities listed below each NIC and select 5 that apply. Write these five on the nursing
care plan in the column labeled activities.
Congratulations!
You have successfully completed your first nursing care
plan using the standardized nursing language vocabularies
of NANDA, NOC and NIC.
NOCs (Outcomes)
Measurement Scale Score:
1 = Severe
2 = Substantial
Respiratory 3 = Moderate
4 = Slight
Status 5 = None
❏ respiratory rate IER*
Ventilation ❏ respiratory rhythm IER
❏ ease of breathing
❏ dyspnea at rest not present
❏ tidal volume IER
❏ vital capacity IER
DATE/TIME
INITIALS