Rawad Pediatric

ISRA University /Faculty of Nursing

Child Health Nursing/ Clinical

Nursing Care Plan

Student Name: Student #:

Date Received:

Total Grade = 50

Final Grade =

Biographical Data:Patient Name: M.M.K (Mohamad Marwan Khalil the name is preferably to be written in initial (M.M.K) in order to maintain the privacy of the patient.) Patient Age: 10 months Birth Date: 16/6/2012 Patient Sex: Male, Patient birth weight: 3.1 kg ward: surgical pediatric ward Medical Diagnosis: Diaphragmatic hernia Sources of information: patient's mother, patients file, team member

Reason for seeking care:

(2 Marks)

As the mother describe:

The child begin to vomiting continuously, crying continuously and increase when touch the child abdomen, decrease in child nutrition, cant sleep for long time, this factors begin to appear on the child since 2 months ago

Health History: History of present illness

(3 Marks)A 10 months old male pt was admitted at 13/4/2012 via ER , C/C abdomen pain recurrent vomiting that lead to irritability for the child ,the child post.op and NPO with NGT , and it begin since 2 months ago , the pain localized at the RUQ and LUQ , duration the irritability and the crying continuously all the time , severity it reflect sever severity according to facial expression and increase in V/S and type , amount of crying can describe as loudly crying ( I used the facial scale but it no effective) the pain localized at the UQ at the location of the operation , the pt post.op ( Repair of the hernia), the pain increase when touch the abdomen and extra movement , slightly decrease at sleeping , associated factors fever , sleep irritability . Crises pain scale:

History of past illness

(2 Marks)

Prenatal status : was well prenatal period from the mother visits , delivery : C/S birth , full term , BW 3.1 kg , childhood illness : free form any disease , PSH: no Hx of PSH , PMH : PMH : pt has jaundice after birth two days that continued 3 days , no Hx of any serious accidents or injuries , not admitted to ICU pediatric , no current problems or medications , immunization : UTD , allergies : NDAKImmunization schedule:

Type of vaccines Given Not given

BCG (

OPV1,2,3 (

DPT1,2,3 (

HBV1,2,,3 (

MMR (

Family History: (3 Marks)

Assessment of growth and development according to chronological age (5 Marks) Developmental phase of the child:

The child is in infant developmental stage because his age is 10 months.Major development stalls or mile stones the child achieved:

Developmental include:

Social Skills

be learning to finger feed

imitate others actions

say "mama" "dada"

understand simple commands

play along side another child

Emotional Development

be very curious about their environment

start to have mood swings and temper tantrums

object when can not have their own way

loving but tend to be self centered in their view of

the world

show separation anxiety when caregiver leaves

Fine Motor Skills

grasp objects with thumb and fore

finger

hold two objects at the same time

drop and pick up objects

can push pull and throw objects

Gross Motor Skills

sit unassisted

pull to standing position

move from lying to sitting position

crawls well

My patient achieved that:

1. he can setting alone without assistance.

2. he can makes sound (e.g. baba) but does not ascribe meaning to them.Erikson : Trust vs. MistrustFreud : Oral phase Physical: Parachute reflex appear , He begins to show regular patterns in bladder and bowel elimination. He can set steadily unsupported and adjust posture to reach an object Fine motor He has beginning to pincer grasp using index. Socialization/Cognition: Increasing anxiety over loss of parent, epically his mother and he fear from strangers. He responds to word (no).

Diaper change and that appear by angry facial expression and crying.

Lifestyle ( Sleep/ Rest Pattern: The patient sleeps about 7 hours at night and about 3 hours afternoon before he was admitted to the hospital, now number of sleep hours decreased related to the condition of the pt ( shortness of breathing, fever,) and the noise in the hospital epically during the visit time .Elimination Pattern ( Bowel Habits: The number of bowel movement is 3 per a day. There is no evidence of constipation, diarrhea. Urinary Habits:The patient has normal urinary habit there is no evidence of dysuria, oliguria, hematuria or retention.Sexual/reproductive Pattern:The patient does not interest or even feelings about the opposite sex, this condition is considerably to be influential by the developmental stage of the patient. Parents education:

- Mother: university - Father: 9th grade Parents occupation:

- Mother: teacher- Father: military* Complete physical Examination:

(5 points)

General survey:

Level of consciousness: The patient is alert , aware and able to respond to sensory stimuli by produce vocal and motor responses ( according to the child developmental stage).

Orientation:

Because the patient is 10 months old so he not oriented to time , place , but

oriented to the person especially family member and he able to differentiate between them and other people.

Vital signs: Heart rate:120 BPM , Normal: 115 beat per min

Blood pressure:135/70 mm Hg , Normal: (65-120/40-80) mm Hg. Respiration rate : 41 breath/min , Normal: 20-40 breath/min. Temperature: 37.2 C , Normal: Axillary ( 36.5 C-37C ) Measurements:

- The length of the child: 70 cm Normal 71 cm - The percentile for the child ( 25 ( between 5 95 )

- The weight of the child: 7 kg Normal: 8.5 kg

- [(age (mo)+9)/2] ( (10+9)/2 = 8.5 kg - The percentile for the child ( 15 ( between 5 95 )

- The head Circumference: 44 cm Normal: 43.4- 45.3cm

- The percentile for the child ( 50 ( between 5 95 )

- The chest Circumference: 45.3 cm Normal: 43.4 - 45.7 cmGeneral appearance: In addition to that the vomiting and hospital environment make him more irritable. Skin: (color) pinkish color ,(texture) moist ,(turgor) elastic, reback after 4 second ,( hair) color appropriate with genetic background, ( nails ) are pink, smooth and hard but flexible. Oral cavity:( lips) symmetric, smooth, and pink in color ,( gums) pink, smooth, no lesion or bleeding, ( tongue) pink in color.Neck: trachea in the midline , no enlargement in the thyroid gland or lymph nods(NLNE).Abdomen:Flat abdomen umbilicus in the midline slightly protruded , scar in the operation location Lung and Thorax: Shallow, Regular respiration with rate 34 breath /min , using accessory muscles . The chest movement is symmetrical .The lung expansion is symmetrical, equal, full expansion. He has bronchal high pitch ,loud amplitude , inspiration < expiration. Bronchovescular moderate pitch, moderate amplitude , inspiration = expiration. Vascular low pitch, soft amplitude , inspiration > expiration breath sounds. And he has wheezing and grunting as adventitious sound. Cardiovascular: Blood pressure of the patient is 135/90 mm Hg , apical pulse on the fourth intercostals space at mid clavicular line , short duration and amplitude , peripheral pulses is strength , even and equal bilaterally with rate 100 beat/min . Musculoskeletal: The patient has full range of motion with no limitation or tenderness in the neck joints, upper extremities joints and lower extremities joints. Spine is firm and even bilaterally , no pain, no tenderness .Cognitive: (eyes) no inflammation , no discharge or lesion, (ears) skin intact ,no lesion, Small size, short pinna(fontanel) posterior fontanel closed .

Lab Investigation: (5 Marks)TestindicationsPt valueUnitNormal valueExplanation

RBCN/A4.611106/ L3.8 5.5Within normal range

HGBN/A11.97g/dL10.2 13.4Within normal range

HCTN/A34.42%33 36Within normal range

MCVN/A74.64fL70 78 Within normal range

MCHN/A25.97Pg/cell25 35Within normal range

PLTN/A264.81000/mm3150 - 300Within normal range

WBCInfection, so patient need take antibiotic19103/ L6 18Related to infection

GLUN/A4.5mmol/L1.1 6.1 Within normal range

UREAN/A0.6mg/dL0.2 0.8 Within normal range

CREAN/A21mol/L18 - 35Within normal range

NaBecause the pt is NPO this lead to decrease the level of Na134mEq/L138 - 145Low from normal

KN/A4.2mmol/L3.5 5 Within normal range

ClN/A104.5mEq/L95 - 110Within normal range

ALTN/A0.16kat/L0.15 1.1Within normal range

PTRegular test pre.op13.8Sec12 - 21Within normal range

PTTRegular test pre.op26.9Sec26 35.5Within normal range

INRRegular test pre.op1.080.9 1.1Within normal range

Medications & Solutions: (5 Marks)Drug NameDose and FrequencyRoutClassification ActionSide effectNursing considerations

Cefizox

350 mg

Q8HIVCeftizoxime (Antibiotic , cephalosporin 3rd generation )

Fever, mild diarrhea , nausea , vomiting , pruritus , rash , itching , thrombocytosis Monitor for super

Infection

Monitor V/S

Observe

For hyperthermia

Record any Change in WBCs

Revanin

250 mgPRN

SyrAcetaminophen

Paracetamol (analgesic/

Antipyretic)

abdominal pain , acute generalized exanthematous, pustulosis ,shock anaphylactoid , reactions anemia angioedema , anorexia , contact dermatitis , edema , elevated hepatic enzymes encephalopathy, erythema ,, fever ,headache ,hemolysis hemolytic anemia hepatic Monitor decrease of folic acid Monitor hypernatremia Monitor V/S

Signs of bleeding,GI pain

Claforan

300mgQ8HIVCefotaxime Ceftizoxime

(Antibiotic , cephalosporin 3rd generation )

Fever, mild diarrhea , nausea , vomiting , pruritus , rash , itching , thrombocytosis Monitor for super

Infection

Monitor V/S

Observe

For hyperthermia

Record any

Change in WBCs

Pethadine

10 mg

StateIMHydrochloride(Narcotic) Analgesic, pain killer GI upset Sedation

Fatigue

Monitor V/S Avoid over dose

Observe any change

On the pt condition

1/5 G/S 200 cc

Q8H( related to

Pt Wt calculation) IVFluid

-------------------- Sings of edema

Changes of pt condition

Monitor V/S

Nursing care plan: (20 Marks)(If there are other relative NDX list them ) Knowledge deficient

Anxiety

Impaired tissue integrity

Body image disturbance

Nursing DiagnosisNursing goalObjectivePlanned interventionRationaleEvaluation

1. deficient fluid volume related to fluid loss G.I ( vomiting) as manifested by

Capillary refill 4 sec Weakness

Irritability Loss of Skin turgor

Child fluid and electrolyte will restored At the end of my intervention the child will demonstrate the following signs and symptoms

Capillary refill 1-2 sec

Skin turgor brisk

V/S appropriate for age

Educate the mother about the intervention

Observe lab tests

Ensure about the IV ( canula ) that placement at the right location (IN ) Administer 1/5 G/S

Monitor IV site for any signs of pain , edema

Monitor V/S

To provide accurate

Information for the mother

about the child status

To take data base for compaction

To prevent any complication for the child

To replacement fluid to avoid dehydration because the pt NPO

To ensure that the fluid enter intravenous and not loss it

To compare if the result changes after the intervention The goal was partially met The capillary refill return to the normal range but the child still irritable and weakness

Nursing DiagnosisNursing goalObjectivePlanned interventionRationaleEvaluation

2.Risk

for infection at

site of surgery

related to post surgical incision

as manifested by

Decrease tissue perfusion

Decrease wound healing

Nutrition imbalance

Malnutrition

To reduce The chance

Of infection

And increase

The understanding

Of risk factor

Of infection At the end of my intervention the child will demonstrate the following Mother

Understanding

About infection and

It`s risk factor

EffectivePrevention of

Infection

Understanding

The risk factor

Of infection Assess the pt`s mother perception

Level of understanding the needs

Obtain pt baseline V/S include pain

Scale To identify and assess the

understanding of the mother

Obtain baseline for future

Comparison

Fever maybe secondary to

Infection The goal Was met The mother

Understood

The importance

Of prevention

The infection

Nursing DiagnosisNursing goalObjectivePlanned interventionRationaleEvaluation

3. fear related to Pain in surgical

Procedure as

Manifested by

Restless

Worry

Pain

Increase

Tension To reduce The degree

Of fear

And feel

More

Relax

At the end of my intervention the child will demonstrate the following

The pt And mother

Will eliminate to

Reduce feeling of

Tension and

Feeling worry and

Panic Establish report on pt

Monitor V/S

Use relaxation technique to reduce the Attention on fear

Provide health education on the pt To establish trust and Cooperation on the pt

And mother

To obtain baseline data

To relax the mind of the

Pt To provide adequate Knowledge on the pt

The goal Was

partially met The mother feel

More relax

But the child

Still crying

And panic

Instructor comments: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you;

2

1

2

1

1

7

Khalil

77 yrs old

Heart attack

Latife

70 yrs old

Waleed

70 yrs old

Halima

66 yrs old

DM , HTN

Marwan

39 yrs old

Fatima

32 yrs old

DM

Note:

The genogram shows that there is Hx of hypertension, DM for grandfather, grandmother and mother and heart attack that lead to death of grandfather and his father healthy in addition to the brothers and sisters are healthy.

Key :

Male

Dead male

Female

Dead female

My pt

Mahmod

21 yrs old

Hadil

17 yrs old

Kareem

12 yrs old

Rana

8 yrs old

Mohamad

10 mon old

Diaphgramic hernia

Continue of nursing diagnosis

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