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Case Scenario #5

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

Fluid volume deficit


Defining Characteristics:
Decreased urine output
Increased body temperature
Decreased skin turgor
Increased pulse rate
Related Factors (Etiology):
Decreased fluid intake

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).

Lynda/NNN/Case Study/Ped ICU 12/14/01 2


Nursing Outcomes (NOCs)

• 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.

Respiratory Status: Gas Exchange


Indicators: Ease of breathing
Dyspnea at rest not present
Cyanosis not present
Neurological Status IER
Restlessness not present
Fatigue not present
Pao2 WNL
Paco2 WNL
O2 saturation WNL

Respiratory Status: Ventilation


Indicators: Respiratory rate IER*
Respiratory rhythm IER
Ease of breathing
Dyspnea at rest not present

*IER = In expected range

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.

Lynda/NNN/Case Study/Ped ICU 12/14/01 3


Nursing Interventions – NIC

Now that you have chosen your outcome for this patient, you will select the
interventions that will best meet this outcome.

• If you have chosen the NOC, Respiratory Status: Gas Exchange


continue below.

• If you have chosen the NOC, Respiratory Status: Ventilation go


to page 6.

NOC - Respiratory Status: Gas Exchange

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.

NIC: Acid-Base Management-Activities (3, p.118)

• 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

Lynda/NNN/Case Study/Ped ICU 12/14/01 4


NIC: Energy Management-Activities (3, p.302)

• Determine pt’s physical • Limit environmental stimuli to • Encourage verbalization of


limitations facilitate relaxation feelings about limitation
• Determine causes of • Monitor nutritional intake to • Determine pt’s/significant
fatigue(e.g. treatments, pain & ensure adequate energy other’s perception of causes
medications) resources of fatigue
• Monitor/record pt’s sleep • Monitor pt for evidence of • Monitor cardio-respiratory
pattern & number of sleep excess physical & emotional response to activity
hours fatigue
• Consult with dietitian about • Arrange physical activities to • Reduce physical discomforts
ways to increase intake of reduce competition for oxygen that could interfere with
high-energy foods supply to vital body functions cognitive function & self-
(e.g. avoid activity immediately monitoring/regulation of
after meals) activity
• Set limits with hyperactivity • Determine what & how much • Monitor location & nature of
when it interferes with others activity is required to build discomfort or pain during
or with the pt endurance movement/activity
• Promote bedrest/activity • Encourage alternate rest & • Limit number of &
limitation activity periods interruptions by visitors
• Use passive &/or active range • Provide calming diversional • Encourage an afternoon nap
of motion exercises to relieve activities to promote
muscle tension relaxation
• Assist pt to schedule rest • Avoid care activities during • Plan activities for periods
periods scheduled rest periods when the pat has the most
energy
• Assist patient to sit on side of • Assist with regular physical • Monitor administration &
bed, if unable to transfer or activities effect of stimulant &
walk depressants
• Encourage physical activity • Monitor pt’s oxygen response • Assist pt to understand
to self-care or nursing energy conservation
activities principles
• Instruct pt/SO to recognize • Instruct pt/so to notify • Teach pt & significant other
signs & symptoms of fatigue health care provider if signs 7 techniques of self-care that
that require reduction in symptoms of fatigue persist will minimize oxygen
activity consumption
• Encourage pt to choose • Assist pt to identify • Evaluate programmed
activities that gradually build preferences for activity increases in levels of
endurance activities
• Assist pt/so to establish
realistic activity goals

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NOC: Respiratory Status: Ventilation

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.

NIC: Airway Management-Activities (3, p. 132)


• Open the airway, using chin lift • Position pt to maximize • Identify pt requiring
or jaw thrust technique ventilation potential actual/potential airway
insertion
• Insert oral or nasopharyngeal • Perform chest physical • Administer bronchodilators
airway therapy
• Encourage slow, deep breathing; • Instruct how to cough • Assist with incentive
turning; & coughing effectively spirometer
• Auscultate breath sounds, • Perform endotracheal or • Remove secretions by
noting areas of decreased or nasotracheal suctioning encouraging coughing or
absent ventilation & presence of suctioning
adventitious sounds
• Teach pt how to use prescribed • Administer humidified air or • Regulate fluid intake to
inhalers oxygen optimize fluid balance
• Administer ultrasonic nebulizer • Monitor respiratory & • Administer aerosol
treatments oxygenation status treatments
• Position to alleviate dyspnea

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NIC: Mechanical Ventilation-Activities (3,p.431)
• Collaborate with physician to • Stop NG feedings during • Instruct pt & family about
use CPAP or PEEP to minimize suctioning & 30-60 minutes rationale & expected
alveolar hypoventilation before chest physiotherapy sensations associated with
use of mechanical ventilators
• Monitor for decrease in exhale • Administer muscle- • Monitor effectiveness of
volume & increase in paralyzing agents, mechanical ventilator on pt’s
inspiratory pressure sedatives, & narcotic physiological & psychological
analgesics status
• Initiate calming techniques • Monitor ventilator pressure • Perform suctions
readings & breath sounds
• Monitor pt’s progress on • Monitor for adverse • Position to facilitate
current ventilator settings & effects of mechanical ventilation/perfusion
make appro. changes ventilation: infections, etc. matching
• Monitor for respiratory muscle • Perform chest physical • Monitor for impending
fatigue therapy respiratory failure
• Promote adequate fluid & • Provide oral care • Monitor effects of ventilator
nutritional intake changes on oxygenation
• Monitor degree of shunt, vital capacity, MVV, Vd/Vt, inspiratory
force, & FEV1 for readiness to wean from mechanical ventilation,
based on agency protocol

Congratulations!
You have successfully completed your first nursing care
plan using the standardized nursing language vocabularies
of NANDA, NOC and NIC.

1. If you wish to received CE for this educational activity, please


complete the evaluation form and return along with $10 to:
Carol Williams, MS, RN, C
Educational Services for Nursing
University of Michigan Health System
300 North Ingalls, 6B12
Ann Arbor, Michigan 48109-0436
2. If you are working with a coordinator please give your quiz,
evaluation and completed nursing care plan to your
coordinator.

Lynda/NNN/Case Study/Ped ICU 12/14/01 7


NURSING DIAGNOSIS Patient Name
Pediatric ICU
Defining Characteristics (Signs & Symptoms)
❏ ❏ ❏
❏ ❏ ❏
❏ ❏ ❏
Related Factors (Etiology)
❏ ❏
❏ ❏
❏ ❏

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

Measurement Scale Score:


1 = Severe
2 = Substantial
3 = Moderate
4 = Slight
Respiratory 5 = None
Status: ❑ ease of breathing
❑ dyspnea at rest not present
Gas
❏ cyanosis not present
Exchange ❑ neurological status IER
❏ restlessness not present
❏ fatigue not present
❏ Pao2 WNL**
❏ Paco2 WNL
❏ O2 saturation WNL
DATE/TIME
INITIALS

*IER = in expected range **WNL = within normal limits


NICs (interventions) ACTIVITIES: MODIFICATIONS:


Energy

Management ❑

DATE/TIME
ACTIVITIES: MODIFICATIONS:
❑:

Mechanical

Ventilation ❏

DATE/TIME
ACTIVITIES: MODIFICATIONS:


Acid-Base

Management ❏

DATE/TIME
ACTIVITIES: MODIFICATIONS:


Airway ❏
Management ❏

DATE/TIME

OTHER INTERVENTIONS: SIGNATURE BOXES:


• •
• •
• •

Lynda/NNN/Case Study/Ped ICU 12/14/01 9

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