NCP for Children

8/18/2019 NCP for Children

1/17

Nursing Care Plan

Diarrhea

Assessment Nursing

Diagnos

is

Background

Knowledge

Planning Interventions Rationale Evaluation

Subjective

Apat na beses

na akong

dumudumi as

"verbalized by

the patient"

Objective

-Loose bowelmovementwith yellowishwatery stoolminimum ofthrice a day.

-Increasebowel sounds/

peristalsis.

-ausea and

!omiting

-Abdominal

cramping

iarrhea

related

to

infectiou

s

processe

s

#esult from

Infectious$vir

al% bacteria

or parasitic&

'

Increaseabsorption of

(uid by the

intestinal

mucosa

'

)yper

motility of

the intestine

'

IA##)*A

+ithin ,

hours of

nursing

interventions%

the patient

will report

reduction in

freuency ofstools and

return to

more normal

stool

consistency

- bserve and

record stool

freuency%

characteristics%

amount% and

precipitating

factors.

- romote bed rest

and

provide bedside

commode.

- #emove stoolpromptly.

rovide room

deodorizers.

- Identify foods

and (uids that

precipitate

-)elps

di0erentiate

individual disease

and assesses

severity of

episode.

- #est decreases

intestinal motility

and reduces

the metabolic

rate when

infection or

hemorrhage is a

complication.

- #educes no1ious

odors to avoid

undue client

embarrassment.

After , hours of

nursing

interventions%

the client was

be able to

report

reduction in

freuency ofstools and

returned to

more normal

stool

consistency


2/17

diarrhea% such as

raw vegetables

and fruits% whole-

grain cereals%

condiments%

carbonated drinks%

and milk products.

- #estart oral (uid

intake gradually.

0er clear liuids

hourly and avoid

cold (uids.

- rovide

opportunity to

vent frustrations

related to disease

process.

-bserve for fever%

tachycardia%

lethargy%

leukocytosis%

- Avoiding

intestinal irritants

promotes

intestinal rest.

- rovides colon

rest by omitting

or decreasing thestimulus of foods

and (uids.

- resence of

disease with

unknown cause

that is di2cult to

cure and that

may reuiresurgical

intervention can

lead to stress

reactions that

may aggravate

condition.


3/17

decreased serum

protein% an1iety%

and prostration.

- Administer

medications% as

indicated3

Antidiarrheals%

such as

dipheno1ylate

$Lomotil&%

loperamide

$Imodium&% and

anodyne

suppositories.

- 4ay signify that

to1ic megacolon

or perforation and

peritonitis are

imminent or have

occurred%

necessitating

immediate

medical

intervention.

- ecreases 5I

motility or

propulsion

$peristalsis& and

diminishes

digestive

secretions to

relieve cramping

and diarrhea.


4/17

Defcient uid volume

Assessment Nursing

Diagnosis

Background

Knowledge

Planning Intervention

s

Rationale Evaluation

Subjective

6)alos

sampung

beses akongdumumi at

apat na beses

na nagsuka%7

as verbalized

by the patient.

Objective

e8cient (uid

volume

related to

e1cessivelosses through

normal routes

as evidenced

by freuent

passage of

loose watery

stool and

#apid

propulsion of

intestinal

contents

through thesmall bowels

may lead to a

serious (uid

volume de8cit.

9he body

would want to

e1pel the

foreign

Short term

+ithin :

hours of

nursinginterventions%

the patient will

report

understanding

of causative

factors for

(uid volume

de8cit

;. lace

patient in

comfortable

position


5/17

• abdominal

cramping

• dehydratio

n

• nausea

• fatigue

• weakness

• dry mucous

membrane

• confusion

vomiting

ob>ective as

much as

possible thus

it doesn?t

undergo its6normal7

speed% with

that% the

digestive

system organs

are not able to

absorb the

e1cess (uids

that are

usually

absorbed by

the body.

Long Term

+ithin = days

of nursinginterventions%

the patient will

maintain (uid

volume at

functional

level as

evidenced by

being well

hydrated%

intake is eual

as output% and

normal skin

turgor

=. 4onitor

input andoutput

balance

:. 4aintain

adeuate

hydration%

increase (uid

intake

@. rovide oral

as well as eye

care

. *ncourage

bed rest

B. Change

accurate

picture of (uid

status

:. 9o correct

losses and

maintain

hydration

status

@. 9o prevent

in>ury from

dryness

. 9o prevent

fatigue

B. 9o reduce

pressure on

fragile skin

Long Term

After = days of

nursing

interventions%the patient

maintained

(uid volume at

functional

level as

evidenced by

being well

hydrated%

intake was

eual as

output% and

normal skin

turgor


6/17

position every

< hours

,. Administer

4etoclopramid

e and

meprazole

:D g asprescribed

E. Feep side-

rails up

;D. iscuss

factors related

to occurrence

and ways to

prevent

dehydration

and tissues

,. 9o limit

gastric and

intestinal

losses

E. 9o avoid

falls since the

patient is

e1periencing

weakness%

fatigue and

confusion

;D. 9o avoid

recurrence of

condition

;;. 9o promote

wellness


7/17

;;. Identify

and instruct in

ways to meet

speci8c (uid

needs

Acute Pain

Assessment Nursing

Diagnosis

Background

Knowledge

Planning Intervention

s

Rationale Evaluation

Subjective

64ahapdi ang

sikmura ko%7 asverbalized by

the patient.

Objective

• !erbalization of pain

Acute pain

related to

gastric

irritation asevidenced by

pain scale of

/;D

5astric

irritation

'

#elease of cytokine and

prostaglandin

'

Increase in

vascular

permeability

'

+ithin ; hour

of nursing

interventions%

the patient willreport a

decrease of

pain

; lace

patient in

supine

position

< *ncourage

patient to

do deep

breathing

e1ercise

; 9o make

the patient

comfortabl

e

< 9o reduce

sensation

of pain

After ; hour of

nursing

interventions%

the patientreported a

decrease of

pain from a

pain scale of

/;D to =/;D


8/17

with a painscale of/;D

• Appearsweak

• Limitedrange ofmotion

• #estlessness

• Impairedthoughtprocess

• #educedinteraction

withpeople

ain in the

abdomen

= Limit

environme

ntal stimuli

such as

noise

: Instruct the

relative to

massage

the area

where pain

is elicited if

not

contraindic

ated

@ *ncourage

doing

diversional

activities%

such asvisualizatio

n%

verbalizatio

n of

feelings or

listening to

music

= *1cessive

environme

ntal stimuli

can

contributeto feeling

of

increasing

pain

: 9o lessen or

alleviate

pain

@ 9o distract

patient?s

attention

from pain


9/17

rovide

adeuate

rest

B Change

position

every <

hours

, rovide

cool

environme

nt

E Feep side-

rails up

;D #eview

ways tolessen

pain%

including

techniues

such as

therapeutic

touch%

biofeedbac

9o reduce

pain and

promote

relief or

comfort

B 9o avoid

bed sores

, 9o make

the patient

feel more

rela1

E 9o promote

patient?s

safety

;D art of

pain

manageme

nt


10/17

k% self-

hypnosis

and

rela1ation

skills

;; Identify

speci8c

signs and

symptoms

and

changes in

pain

characteris

tics

reuiring

medical

follow-up

;; 9o promote

timely

interventio

n


11/17

edications

DR!" C#A$$I%IC

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(me+ra,o

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NAE*

Losec-Prilo

sec

gastrointesti

nal

agentG +rot

on +um+

inhi.itor

/0g I) (D

An

antisecretory

compound that

is a gastric acid

pump inhibitor.

Huppresses

gastric acid

secretion by

inhibiting the

)% F-A9ase

enzyme system

Jthe acid

$proton )&

pumpK in the

parietal cells.

uodenal and

gastric ulcer.

5astroesopha

geal re(u1

disease

including

severe

erosive

esophagitis

$: to , wk

treatment&.

Long-term

treatment of

pathologic

hypersecreto

ry conditionssuch as

ollinger-

*llison

syndrome%

multiple

endocrine

adenomas%

and systemic

Long-term

use for

gastroesopha

geal re(u1

disease%

duodenal

ulcersG

lactation.

CN$*)eadach

e% dizziness%

fatigue.

"I*iarrhea%

abdominal

pain% nausea%

mild transient

increases in

liver function

tests.

!rogenital*)

ematuria%

proteinuria.

$kin*#ash.

Lab

tests3

4onitor

urinalysis

for

hematuria

and

proteinuri

a. eriodic

liver

function

tests with

prolonged

use.


12/17

mastocytosis.

In

combination

with

clarithromyci

n to treat

duodenal

ulcers

associated

with

)elicobacter

pylori.

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NAE*

obutamin

e

BRAND

NAE*

obutamin

e

)ydrochlori

de

Inotropic

agent

obutamine

drops < ampule

obutamine is

an inotropic

agent whose

primary

activity is the

stimulation of

beta receptors

of the heart

while

producing

comparatively

mild

chronotropic%

hypertensive%

arrhythmogeni

-Hevere

cardiac

failure

secondary to

A4I or

cardiomyopat

hy.

-Cardiogenic

shock.

-Heptic

shock.

-Congestive

Idiopathic

hypertrophic

subaortic

stenosisG

hypersensitivi

ty to any

component of

the productG

dobutamine

with de1trose

should not be

administered

simultaneousl

y with blood

through the

1eart-Increasedheart rateand bloodpressure%chest pain%palpitation.

#ocal-In(ammationof vein.

iscellaneous- ausea%vomiting%headache%

Ideally monitor

M

continuously.

A catheter

often desirable.

-atient must

be on cardiac

monitor.

- *C5% M% and

hourly urine

measures must

be

continuously

monitored

while A+


13/17

c and

vasodialative

e0ects.

Causes an

increase in

cardiac output

$C.& usually

not associated

with a marked

increase in

heart rate%

while the

stroke volume

is usually

increased.

Hystemic

vascular

resistance is

usually

decreased due

to stimulation

of beta <

receptors

which

contributes to

the increased

C..

cardiac

failure.

-Acute

pulmonary

oedema

same infusion

set because

of the

possibility of

pseudoagglut

ination of red

cells.

an1iety%fatigue andshortness ofbreath

Potentiall2%atal-)eartdiseases.

and C. should

be monitored

wherever

possible.

- obutamine

is chemically

stable for


14/17

"ENERIC

NAE*

aracetam

ol

BRAND

NAE*

Miogesic%

anadol%

9ylenol

on-

narcotic

analgesic% A

nti+2retic

er rem3

@DDmg :h for

temp. above

=B.,

-ecreases

fever by a

hypothalamic

e0ect leading

to sweating

and

vasodilation

-Inhibits

pyrogen e0ect

on the

hypothalamic-

heat-regulating

centers

-Inhibits CHprostaglandin

synthesis with

minimal e0ects

on peripheral

prostaglandin

synthesis

-oes not

cause

ulceration ofthe 5I tract

and causes no

anticoagulant

action.

-Control of

pain due to

headache%

earache%

dysmenorrhe

a% arthralgia%

myalgia%

musculoskele

tal pain%

arthritis%

immunization

s% teething%

tonsillectomy

-9 reduce

fever in viraland bacterial

infections

-As a subs-

titute for

aspirin in

upper 5I

disease%

bleeding

disordersclients in

anticoagulant

therapy and

gouty

arthritis

-#enal

Insu2ciency

-Anemia

-4inimal 5I

upset.

-4ethemo

5lobinemia

-)emolytic

Anemia

-eutropenia

-

9hrombocyto

pe

ia

-ancytopenia

-Leukopenia

-Nrticaria

-Liver

amage

-o not e1ceed

:gm/


15/17

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NAE*

4etoclopra

mide

BRAND

NAE

Clopra%

*me1 %

4a1eran %

a3olon-

#eglan*

gastrointesti

nal agentG

prokinetic

agent $gi

stimulant&G

autonomic

nervous

system

agentG

direct-acting

cholinergic

$parasympat

homimetic&G

antiemetic

, # otent central

dopamine

receptor

antagonist.

Htructurally

related to

procainamide

but has little

antiarrhythmic

or anesthetic

activity. *1act

mechanism of

action not clear

but appears to

sensitize 5I

smooth muscle

to e0ects of

acetylcholine by

direct action.

4anagement of

diabetic gastric

stasis

$gastroparesis&G

to prevent

nausea and

vomiting

associated with

emetogenic

cancer

chemotherapy

$e.g.% cisplatin%

dacarbazine&G

to facilitate

intubation of

small bowelG

symptomatic

treatment of

gastroesophag

eal re(u1.

Hensitivity or

intolerance to

metoclopramide

G allergy to

sul8ting agentsG

history of

seizure

disordersG

concurrent use

of drugs that

can cause

e1trapyramidal

symptomsG

pheochromocyt

omaG

mechanical 5I

obstruction or

perforationG

history of breast

cancer. Hafety

duringpregnancy

$category M& or

lactation is not

established.

CN$*

#estlessne

ss

%

drowsiness

%

fatigue%

insomnia

dizziness%

an1iety

C)*

tansient

hypertensi

on

"I*

nausea

and

diarrhea

#eport

immediately the

onset of

restlessness%

involuntary

movements%

facial grimacing%

rigidity% or

tremors.

*1trapyramidal

symptoms are

most likely to

occur in children%

young adults%

and the older

adult and with

high-dose

treatment of

vomiting

associated with

cancerchemotherapy.

Hymptoms can

take months to

regress.

Me aware that

during early

treatment period%

serum


16/17

aldosterone may

be elevatedG

after prolonged

administration

periods% it

returns to

pretreatment

level.

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NAE*

piperacillin

and

tazobacta

m

BRAND

NAE*osyn

Antibiotic :.@L4H

9hen


17/17

)gb% CMC with

di0erential and

platelet count&.

4onitor patient

carefully during

the 8rst =D min

after initiation of

the infusion for

signs of

hypersensitivity

$see Appendi1 R&.

Documents

NCP for Children