Needs/ Problems Cues

Nursing Diagnosis

Objectives of Care After 8 hours of holistic nursing care, the patient will be able to:

Nursing Actions

1. CROUP SYNDROME 1.1. Acute Epiglottitis I. Physiologic Deficit i. Hypoxia Objective cues: Swallow color of skin Suprasternal & substernal retractions are visible - child is extremely restless -

Impaired gas exchange: decreased oxygen level in the tissues r/t severe inflammatory obstruction of the epiglottis

1.1improve adequate oxygenation of tissues

1.1. Measures to improve gas exchange 1.1.1. monitor respiratory status of the patient continuously 1.1.2. position the child that provides him/her the most comfort & security 1.1.3. administer humidified oxygen via mask as indicated by the physician 1.1.4. administer antibiotics as prescribed by the doctor

1.2. Acute Laryngotracheobronchiitis I. Physiologic deficit ii. Difficulty in breathing

Ineffective breathing pattern: difficulty in breathing r/t obstructive inflammation of the mucosa lining of the larynx and trachea

1.2 manifest signs of improvement in the breathing pattern

1.1.5. administer corticosteroids as prescribed by the doctor 1.2. measures to improve breathing pattern 1.2.1. instruct the parent to provide the child cool air

Objective cues: presence of inspiratory stridor - suprasternal retractions - nasal flaring -

2. TONSILLITIS I. Physiologic overload a. Pain in swallowing - the patient complained about pain in swallowing - inflamed palatine tonsils seen. - The tonsillar tissue appears bright red

Alteration in comfort: Acute pain in swallowing r/t inflammation of the palatine tonsils Altered thermoregulation: hyperthermia r/t infection of the palatine tonsils

2. verbalize a decrease degree of pain from 7 to 4 with the use of pain scale Manifest reduction of temperature from 38.9 to 37.5

at home such as taking the child outside to breathe in cool night air, using a coldwater vaporizer or humidifier, standing in front of the open freezer and taking the child to a cool basement or garage 1.2.2. encourage parent to use comforting measures with their child such as holding, rocking, walking and singing 1.2.3. monitor respiratory status accurately and continuously. 1.2.4. administer high humidity oxygen with coolmist as prescribed by the doctor 1.2.5. administer nebulized epinephrine (racemic epinephrine) as prescribed by the doctor 2. Measures to reduce the intensity of pain 2.1. Advice the parents that a soft to liquid diet is preferred for their child 2.2. instruct the parent to let their child gargle with warm saltwater 2.3. Advise the parent to use throat lozenges 2.4. Administer analgesic-

3.PHARYNGITIS I. Physiologic overload a. Sore throat Objective cues: - erythema present in the back of the pharynx & palatine arc - difficulty in swallowing - the child complains of sore throat

Alteration in comfort: Acute pain in the throat r/t inflammation of the pharynx

3. verbalize a decrease degree of pain from 7 to 4 with the use of pain scale

antipyretic drugs such as acetaminophen as prescribed by doctor 2.5. Assist in tonsillectomy 3. measures to reduce the intensity of pain 3.1. instruct the parent to apply warm compress to the external neck area using a warm towel or heating pad 3.2 instruct the parent or child to gargle with a solution such as warm water 3.3 encourage the parent and child to eat ice chips 3.4 administer acetaminophen as prescribed by the doctor 3.5 administer oral penicillin as prescribed by the doctor 4.Measures to prevent further loss of blood volume 4.1 frequent monitoring of v/s especially BP 4.2 keep the child on bed rest 4.3 record the approximate amount of blood lost in stools

4. prevent further loss of blood volume 4. MECKELS DIVERTICULUM I. Physiologic deficit a. Intestinal bleeding Objective cues: - hypotension - painless bleeding in the rectum with a currant jellylike stools - abdominal distention Fluid volume deficit: continuous bleeding r/t perforation from the unbuffered acidic secretion Alteration in comfort: abdominal pain r/t irritated bowel wall due to misplaced gastric mucosa 5. control signs and symptoms of lactose intolerance Imbalanced nutrition: less than body requirements r/t inability to absorb lactose in the small intestine Altered bowel elimination: Verbalize relief of pain and demonstrate relax body posture

5. LACTOSE INTOLERANCE I. Physiologic deficit a lactase deficiency Objective cues:

Restore normal bowel functioning as evidenced by normal bowel sounds

- bloating - flatulence - positive on breath hydrogen test

diarrhea r/t inability to absorb lactose in the small intestine

4.4 administer IV Fluids as prescribed by the doctor 4.5 assist in blood replacement 5. measures to control signs and symptoms of lactose intolerance 5.1 advise the parents to substitute soy-based formula for cows milkbased formula or human milk 5.2 advise the parents to use enzyme tablets 5.3 advise the parents to let their child drink with other foods rather than alone 5.4 advise the parents to take Vitamin D & calcium supplementations 5.5 Instruct the parent the alternative sources of calcium such yogurt, hard cheese, cottage cheese 6. measures to improve nutrition 6.1 refer to nutritionist 6.2 instruct the parents to observe a gluten-free diet 6.3 advise parents to use substitute grain foods such as corn, rice and millet 6.4 advise parents of the

6. Imbalanced nutrition: less than body requirements r/t malabsorption of food across the intestinal villi into the bloodstream

6. CELIAC DISEASE I. physiologic deficit a. Imbalanced Nutrition objective cues: - distended abdomen - appears skinny - wasted buttocks

7. Altered bowel elimination: Chronic constipation r/t inability of the internal sphincter to relax/ loss of rectosphincteric reflex

7. HIRSCHSPRUNGS DISEASE I. Physiologic overload a. constipation Objective cues:

- chronic constipation with ribbonlike stools - abdominal distention - foul-smelling stools 8. improve absorption of water and electrolytes Altered bowel elimination: diarrhea r/t poor absorption of water and electrolytes secondary to inflammation of mucosa of the colon

necessity of reading all label ingredients carefully 6.5 instruct parent to let their child take vitamin A,D,E & K, folate and iron supplements 7. measures to improve bowel elimination 7.1 instruct parent to perform enemas 7.2 advise parent to provide a low-fiber, a highcalorie and a high-protein diet 7.3 Administer GoLYTELLY thru NG tube as prescribed by the doctor 7.4 assist in pull-through procedure 7.5 instruct parents on colostomy care

8. ULCERATIVE COLITIS & CROHN DISEASE I. Physiologic deficit a. diarrhea Objective cues: - child had feeling of urgency with defecation - presence of blood in the stool - abdominal pain

9. Maintain skin integrity 8. Measures to improve absorption of water and electrolytes 8.1 encourage parents for supplementation of multivitamins, iron and folic acid 8.2 advise the child to rest 8.3 advise the parent to observe a high-protein & high-carbohydrate diet & avoid foods containing fiber 8.4 encourage parents to

Activity intolerance: limited activity r/t improper formation of the hip 9. DEVELOPMENTAL HIP DYSPLASIA Risk problem Objective cues: - the infant is wearing a brace - Galleazzi sign is seen Risk for impaired skin integrity r/t prolonged wearing of braces

- Trendelenburgs sign is seen 10. increase the strength and function of the hip joint

use fish oils 8.5 administer enteric formulas by mouth/ by continuous NG tube infusion as prescribed by the doctor 9. measures to maintain skin integrity 9.1 always put an undershirt under the chest straps and put knee socks under the foot and leg pieces. 9.2 check frequently at least 2 to 3x a day for red areas under straps and clothing 9.3. gently massage healthy skin once a day to stimulate circulation 9.4 always place diaper under straps 9.5 teach parents regarding the proper care of cast 10. measures to increase the strength and function of the hip joint 10.1 promote bed rest 10.2 advise the use of nonweight bearing 10.3 encourage the parent/ child for active motion 10.4 administer NSAIDs as

Impaired physical mobility: Difficulty in walking r/t decrease of strength in the hip joint 10. LEGG-CALVE-PERTHES DISEASE I. Physiologic deficit a. Difficulty in walking Objective cues: - limp appearance - hip stiffness - pain in the hip, entire thigh and knee joints Impaired physical mobility: loss of ability to walk r/t muscular wasting & weakness

11. manifest signs of improvement of the muscle demonstrate techniques and behaviors that enable resumption of activities

11. DUCHENNES MUSCULAR DYSTROPHY I. Physiologic deficit a. loss of ability to walk Objective cues: - difficulty in rising from a sitting or supine position - difficulty in running, riding a bicycle and climbing stairs - muscles become enlarged

12. verbalize a decrease degree of pain from 7 to 4 with the use of pain scale

and feel unusually firm or woody on palpation 12. OSGOOD SCHLATTER DISEASE I. Physiologic overload a. Pain in the knee Objective cues: -pain is aggravated by running and squatting - swelling of tibia tubercle - pain in the tibia tubercle 13. JUVENILE ARTHRITIS

Alteration in comfort: Pain in the knee r/t inflammation of the apophysis of the tibial tubercle

prescribed by the doctor 10.5 assist in pelvic/femoral osteotomy 13. 11. measures to improve muscle strength/ to improve physical mobility 11.1 provide ROM exercise daily 11.2 encourage the parent & child to remain ambulatory 11.3 provide strength & muscle training 11.4 provide stretching exercise 11.5 provide breathing exercise

Activity intolerance:limited motion r/t painful hip and knee joints

14. participate in increasing function of the affected body part

12. measures to reduce the intensity of pain 12.1 advise the child to rest 12.2 advise the parent to limit strenuous activities 12.3 apply ice on the affected area 12.4 administer NSAID as prescribed by the doctor 13. measures to improve activity tolerance 13.1 advise parent to apply moist heat on the

14. SYNDACTYL

Impaired physical mobility: difficulty in grasping objects r/t webbing of the rmf and lmf

15. establish normal effective respiratory pattern

15. PECTUS DEVIATION

Ineffective breathing pattern: dyspnea r/t increased anteriorposterior diameter of the chest

affected area 13.2 advise parent to give their child a warm bath with a temperature of 37.8oC for less than 10 mins. 13.3 advise the parent to let their child engage in swimming activites 13.4 advise parent that their child should have 8-10 hours of nighttime sleep 13.5 advise parent to provide simple isometric/ tensing exercises that do not involve joint movement 14. measures in improving the affected body part 14.1 inspect and count the number f fingers and toes 14.2 inspect the arms and legs for temp. and color which should be equal in each extremities 14.3 observe the ROM of the extremities throughout the entire examinations 14.4 instruct parents to have schedule activities with adequate rest periods during the day 14.5 identify energy conserving tech. for activities of daily living

16. mobilize the neck without difficulty

16. TORTICOLLIS Impaired physical mobility: limited neck movement r/t injury of the sternocleidomastoid

muscles during delivery

17. CRANIOSYNOSTOSIS Risk for delayed development r/t premature closure of the sutures of the skull 18. verbalize acceptance of self in situation having achondroplasia

15. measures to improve breathing pattern 15.1 stress the importance of good posture and effective use of accessory muscle 15.2 encourage position of comfort 15.3 assist client in breathing restraining (diagphragmatic,abdominal breathing, inpiratory resistive and purse lip as indicated) 15.4 encourage adequate rest periods between activites 15.5 administer oxygen as prescribed by the doctor 16. measures to promote mobility 16.1. promote gentle strecthing exercise 16.2. place the child in a crib or playpen in a way encouraging turning his head away fron deformity to observe activities and interesting items 16.3. encourage feeding and playing with the child to encourage turning the head for the desired direction for correction 16.4. instruct the parent to

18. ACHONDROPLASIA

Disturbed body image: negative feelings about self r/t stunted upper and lower extremities

19. manifest signs of improvement of leg

movement

19. TALIPES DEFORMITIES

20. NEPHROTIC SYNDROME 21. DIAPER DERMATITIS Impaired physical mobility: limited leg movement r/t deformed ankle and foot Fluid volume excess: edema r/t glomerular injury Alteration in comfort: itchiness r/t exposure of irritated skin due to excretion such as urine or stools

place a mobile on the child cribs crib to encourage child to look toward the affected side. 16.5. instruct the parents that the head of the child is turned toward the affected muscle and face is tilted in the opposite direction with the neck extended. 17. measures to
17.1 measure head circumference 17.2 observe for changes in neurologic status 17.3 provide fluids and adequate hydration 17.4 monitor hematocrit and hemoglobin levels 17.5 advise the parent that eye care should be limited to gentle cleansing with a moist cloth 18. measures to promote selfesteem

18.1. establish nurse-client rel. carrying an attitude of caring and developing sense of trust 18.2. discuss concerns about fear, mutilation rejection and poor socialization. 18.3.have client describe self and be aware of how client becomes others to see self.

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