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Running head: PEDIATRIC CARE PLAN 1

Pediatric Formal Care Plan

Ness Mickey

Nursing 318: UHNBC Pediatric Clinical

November 10th, 2017

Jas Johal & Darlene Nestle, RN, BScN

University of Northern British Columbia – Quesnel

PEDIATRIC CARE PLAN 2

Pediatric Formal Care Plan

Student Name: Ness Mickey

Health Care Setting: UHNBC – Pediatric ward

Demographic Data: Lower-class, Caucasian family

Admitting Medical Diagnoses: Uncontrolled Dystonic episodes secondary to Cerebral palsy (CP)

Allergies: Ativan (Lorazepam)

Living will: No record of a living will on file

Code Status/Advanced Directive: Full-code

Age of Client: 2 years old

History of Present Illness: Timmy has been in and out of hospital most of his life to treat and manage his symptoms that he experiences frequently regarding his seizure activity, secondary to his cerebral palsy. He has very strong dystonic episodes related to his cerebral palsy, and is dependant upon his J+G-tube for nourishment.

Past Medical History:

Medical HistoryTimmy was jaundice at birth. Since

then there has been significant medical issues. Timmy has been in and out of hospital most of his life.

Surgical History Timmy has had a J+G-tube

inserted to increase optimal GI function.

Social HistoryTimmy’s mother appears to be very

flat affect. She does not seem to want to be involved in any portion of his care and knows very little

about any aspect of Timmy’s care. Social concerns with family

dynamic are evident due to this withdrawn behaviour by mom.

However, Timmy’s father is very knowledgeable about his care, and

takes a significant role in any interventions/management around

Timmy’s diagnosis.

Vital Signs:______________________________________________________________________________

Day 1Temperature: Axilla 37.5 degrees Celsius (Timmy’s normal) Oral: N/A Rectal: N/ABlood Pressure: Lying: 133/71mm/Hg Standing: N/A (client cannot stand)Pulse: R - 130 bpm Respirations: 35/minuteO2 Saturations: 98% at room air (RA)


Current Weight: 13 kg OR 28.6 lbs

Day 2Temperature: Axilla 36.8 degrees Celsius Oral: N/A Rectal: N/ABlood Pressure: Lying: 130/72mm/Hg Standing: N/A (client cannot stand)Pulse: R 140 bpm Respirations: 32/minuteO2 Saturations: 96% at RA

Day 3Temperature: Axilla 36.5 degrees Celsius Oral: N/A Rectal: N/ABlood Pressure: Lying: 136/67mm/Hg Standing: N/A (client cannot stand)Pulse: R 137 bpm Respirations: 33/minuteO2 Saturations: 98% at RA

Risk for Altered Body Temperature: Yes

Related to: The client is at risk for altered body temperature because of immobility and incontinence,

which puts the client at risk for skin break down and urinary tract infections.

Biophysical Dimension

______________________________________________________________________________

Pain/Altered Comfort Lab/Diagnostic Data

P: Client is unable to state any source of pain, and did not show any extra linguistic factors of communication that indicated pain.

Q: Parents did not indicate any signs that their child was in pain.

R: No grimacing, crying, or physical indication of pain.

S: Client is unable to state any level of severity of pain.

T: Father confirmed that he was unable to identify any signs that his child was in pain.

Although there was no indication that Timmy was in pain, his PRN dose of Tylenol was given before the beginning of shift. Only one dose was needed to reach a therapeutic effect as evidence by Timmy’s ability to settle down.

The client is taking PRN Acetaminophen 180mg q4h for pain. The client usually exhibits signs of pain once or twice throughout a shift, and seems to settle with one dose. The client is unable to use any sort of pain assessment tool such as “FACES” but conveys pain through extra linguistic communication such as grimacing, crying, and/or lots of moving when lying in bed.

Neurologic Lab/Diagnostic Data


No facial droop. Minimal strength to all limbs due to CP Pupils are a size 3 bilaterally and equally

reactive Adequate grip to both left and right side of

body Hard/stiff muscle tone due to CP and dystonic

episodes

Cranial Nerves assessment:1) CN I (olfactory): Undetermined2) CN II (optic): Undetermined3) CN III (oculomotor): Undetermined4) CN IV (trochlear): Undetermined5) CN VI (abducens): III. IV. & V. tested

together. Client’s pupils are size 3, round, symmetrical, and papillary reactions to light are reactive and equal bilaterally.

6) CN V (trigeminal): Undetermined7) CN VII (facial) – Undetermined8) CN IX (glossopharyngeal): Undetermined9) CN X (vagus) – IX. & X: Undetermined10) CN XI (spinal accessory): Client able to move

head indicating adequate use of the sternocleidomastoid muscle. Client involuntarily able to push shoulders up against resistance indicating adequate upper trapezius muscle strength.

11) CN XII (hypoglossal): Tongue is midline and symmetrical and does not exhibit any muscle twitching.

Client’s body is slightly tilted to either side due to desire to relieve stress on pressure from dystonic episodes.

Atrophy to lower limbs and arms due to immobility caused by CP and neurodegenerative disease.

Client unable to vocalize any headaches, numbness, or tingling.

Paediatrician and resident in to assess client, and distinguished that a neurological disorder may be contributing to the client’s continuing declining condition(s).

Neurodegenerative Disease:Share common pathogenetic mechanism involving aggregation and deposition of misfolded proteins, which leads to progressive central nervous system

Client was awake throughout all assessments and procedures and continued to have dystonic episodes throughout the day. Client also displayed nystagmus eye movements, these eye movements never ceased.


disease (Skovronsky, Lee & Trojanowski, 2006).Cardiac Lab/Diagnostic Data

Clients’s BP does not show any signs of hypo/hypertension.

S1 & S2 heart sounds present. No abnormal heart sounds including S3 & S4 present.

Apical pulse present and regular. Both brachial pulses present and symmetrical.

Rhythm is consistent, no bounding present. No bruits, thrills, murmurs, or rubs present

upon auscultation. Blood pressure completed while resident was

in lying position. BP: 133/71mm/Hg. No concerns.

No neck distension present. Unremarkable capillary refill. Nail beds are pink in color and show no signs

of clubbing or cyanosis. Lips are pink in color. Temperature is consistent in lower limbs as

well as both arms. No edema present.

InspectionPalpationPercussionAuscultation

Blood tests completed and on file.

Respiratory Lab/Diagnostic Data

Clients’s O2 is 98% at room air. Cough and sputum present – thick oral

secretions. Suctioned with oral suction and effective.

Respiratory rate is 40/minute fast, but regular. Chest expansion and chest is symmetrical. Adventitious breath sounds to all four lobes,

decreased air entry throughout, but more prominent to the right lower lobe. Chest sounds moist and wet throughout all four lobes.

Client is using assessor muscles to breath, but does not show any signs of struggle.

Client does currently express signs of respiratory issues, and takes both Ventolin and Flovent to resolve these issues.

InspectionPalpationPercussionAuscultation

Frequent appointments with the respiratory therapist (RT) utilized and in chart.

Pneumovax Inoculation not on file.

Tuberculosis Screening Tool not on file.

Gastrointestinal/Nutrition Lab/Diagnostic Data

Abdomen is symmetrical upon inspection. Bowel sounds auscultated in all four

quadrants. Last bowel movement reported was witnessed

earlier in the day (AM).

InspectionAuscultationPercussion


Skin is warm to touch and well perfused. Client currently receives his nutrition via G-

tube, and appears to tolerate it well most days, with the exception of periodic regurgitation witnessed during flushing and administering medications.

Client currently receives 167 mls of Nutren Jr. with 114 mls of Pedialyte via continuous run (24/7) of G-tube.

G-tube must be changed every 4 hours. Client has normal and regular bowel

movements. Client was regurgitating thick oral secretions

throughout assessment, but this was alleviated by oral suction with effectiveness.

Palpation

Dietician assessment on file.List of “recipe” for feeds on file, and in chart.

Genitourinary/Gynecologic/Reproductive Lab/Diagnostic Data

Client is on Ins&Outs, which are measured by weighing clients diaper.

No penial discharge or abnormalities present. Testicles are distended, and exhibit no signs of

swelling or abnormalities. In&Out record sheet by client’s bedside to

promote mom and dad to write down any observed Ins or Outs.

Urine is clear amber color and quantity sufficient output.

Client wears diapers, and is changed on a regular basis to prevent infection and any skin break down.

Ins&Outs recorded, and in file.

Integumentary Lab/Diagnostic Data Client’s skin was warm and dry to touch. No

concerns. Skin was pink, and well perfused. Skin turgor indicated resident was well

hydrated. No concerns. Oral mucosa, pink and moist. No concerns. Client receives frequent bed baths while in

hospital, but does not have good hygiene at home as evidence by frequent admissions to the hospital.

Parents deny child having xerosis, pruritus, rashes, or changes in skin pigmentation or color.

Parents deny any changes to skin with changing of seasons.

Toe nails were intact. No splitting, discoloration, breaking or separation from nail bed present.

Serous/sanguineous exudate discharge from umbilical area where G-tube is placed. No odour present. Edge of wound is excoriated but

InspectionPalpation

Braden Scale on file. Score is 14, which indicates client is at moderate risk for skin breakdown.


looks healthy. Client fuses and grimaces indicating pain during dressing changes that are due bid. Treatment followed as per treatment plan and documented in Client’s chart.

Client is at risk for moderate skin breakdown due to his immobility and incontinence.

Client is partially bed-ridden and therefore at risk for skin breakdown that may possible lead to pressure ulcers.

Pressure Ulcers:Pressure ulcers develop based on the amount of moisture, pressure, friction, shearing, and age related malnutrition, anemia, and low arterial pressure that the resident is exposed to. Also, the likelihood of developing pressure ulcers later in life increases as we age. Quality of care is also a contributing factor to the prevalence of developing pressure ulcers (Touhy & Jett, 2012).

Musculoskeletal Lab/Diagnostic Data

Client exhibits signs of a neurodegenerative disease as evidence by symptoms secondary to his CP, including dystonic episodes.

Easily transferred from bed to chair. Muscle tone is overbearing as a result from CP Client exhibits a wide range of motion (ROM)

in his legs, and arms. Client does not have satisfactory eye-hand

coordination.

Physiotherapist appointments available.

Renal/Metabolic Lab/Diagnostic Data

The kidneys loose about 50% of the nephrons. The kidneys cortex has a decrease in size and function. The GFR is decreased which causes urine creatinine clearance to require a lower does of medication (Touhy & Jett, 2012).

Because of the J+G-tube adaptation the client is at risk for electrolyte imbalances; therefore, it is important to take his electrolyte levels regularly.

Chronic Kidney Disease:Different disease processes can affect kidney function. Diet, drugs, and disease progression can be key factors in developing CKD (www.bcguidelines.ca/pdf/ckd.pdf).

On October 30th 2017 the client’s lab values for his urine analysis showed that her creatinine was 13, which was low. Normal range for UA creatinine is between 45-84. The client’s glomerular filtration rate (GFR) was 57, which is low. Normal GFR is greater or equal to 60. Low GFR and high creatinine can be related to chronic kidney disease. A urine test could be used to evaluate pH, and kidney function (Ebersole & Hess, 2012).

GFR less than 60ml/min/1.73 m2 for 3 months is a diagnostic


criterion for CKD (www.bcguidelines.ca/pdf/ckd.pdf)

Sodium level was 135, which is a bit on the low side. (136-145).

Potassium level was elevated at 7.3, this was considered to be a critical level. (3.5-5.1).

Immune/Hematopoietic Lab/Diagnostic Data

The client is MRSA+ The client has hx of RSV, but has since been

vaccinated. The client is up-to-date on all vaccinations The client is incontinent of BMs/ urine and

requires diaper changes frequently throughout the day. By changing the client’s diaper throughout the day infections can be avoided.

On October 30th 2017 the client’s lab values were as follows:- White blood cell: 11.3 x 10(9)/L, which is high. Normal range is between 4 and 10 x 10(9)/L.- Red blood cell: 4.40 x 10(12)/L, which is normal. Normal range is between 4.30 and 5.50 x 10(12)/L.- Hemoglobin: 122 g/L, which is low. Normal range is between 135 and 170 g/L.

Behavioural Dimension

Activity/Rest & Sleep

The client sleeps/ rests in bed throughout the day as a result from being bed-ridden by his disease. The client is immobilized due to his comorbidities, and needs full assistance with ADLs. The client is small enough for easy transfers now, but will require a full lift for transfers when he is older. The client’s father states that the client has a regular sleeping schedule and often sleeps a lot during the day, and can be quite restless at nighttime. The client is unable o use a pacifier at nigh time, and is limited to teething options as he does not tolerate things in his mouth for long periods of time due to his dystonic episodes and CP.

Consumption Patterns

The client is currently being nourished through G-Tube feeds, and requires full dependence upon parents for all nutritional requirements. The client’ parents deny any history of addiction


to illicit substances. Denies any current of past history of drug use. The client remained in a lying position during all medication administration throughout writer’s clinical shifts.

SexualityThe client is currently just 2 years old. Sexuality is not applicable to this client.

SafetyThe client has impaired hand-eye coordination and therefore, is a risk for falls. He does require all four bed-rails up when in his crib. The client does not require glasses, but is positive for nystagmus, which would impair his vision significantly. He is unable to vocalize any such impairment. The client does not have hearing aids. Currently, the client exhibits dystonic episodes that contribute to the exacerbation of muscle movements, and is unable to control or cease these movements. He is not able to bring his arms and hands to face and therefore is not able to put anything in his mouth. The client can however sit up in his crib with assistance and use his abdominal muscles appropriately.

Psychological Dimension

Self-Concept/Self-PerceptionUpon assessment the client’s mother appears to be extremely withdrawn from any portion of her child’s care as evidence by very flat affect, and no knowledge at all of her child’s care being provided. The father appeared to be very eager to participate in all stages of care. Staff should encourage the client’s parents to possibly seek professional guidance in dealing with their situation. Staff should also support the client in attending support groups around CP to help the resident explore and express his feelings towards his condition. The client currently does not appear to have any sense of self-concept/ self-perception, but the earlier these interventions are started, the more effective they tend to be.

Stress/CopingThe client does not seem to respond to anything that indicates stress-relief.


Sociocultural Dimension

Role/Relationships

The client relies predominantly on his relationship with his parents for support. When asked about any past or current history of abuse, the client’s family denied any experiences of the sort. The client continues to develop his relationship with his parents, but appears to rely more on dad than mom. Mother appears flat in affect, and not involved in client’s care whatsoever. Client comes from a family of six children, plus mom and dad. Therefore, the client exhibits true dependence on his family for survival.

Values/Beliefs

No religious beliefs or cultural practices were identified during the interview.

Physical /Environmental Dimension

Living Arrangements/Pets

The client currently lives at home with his parents and six other siblings. The parents speak only English, and have not considered learning sign language for when their son is older. They do not own any pets, and live on a very tight budget as evidence by the father stating, “we don’t have much, we just do what we can”.

Health System Dimension

Health Perception - Health Management Pattern

Currently, the client’s primary healthcare provider is Dr. Doe. Dr. Doe believes that Timmy is suffering from some sort of neurological disorder with regards to his CP. Dr. Doe also believes that Timmy is exhibiting worsening signs dystonic episodes. The client is up-to-date with his immunizations. The main priority for this client is to prevent further skin breakdown, and promote wellbeing through socialization. ADLs are done everyday for this client, and diaper changes are required throughout the day. The resident does not have issues waking up in the morning and is G-tube fed throughout the day, continuously.


Client’s Discharge Planning Needs

Currently, the client requires a level of professional services that could not be offered at home. For

example, the client suffers from dystonic episodes secondary to his CP, and is susceptible to

infections, and needs an advance level of care most of the time. It would be both unethical, and unsafe

Diet & Routine/PRN Treatments Patient Learning Needs(During days of care)

Client receives fed through G-tube, continuously throughout the day (24/7). The resident frequently regurgitates food after feeds, and medication administrations and flushes. This is treated with suctioning, and sitting client up in crib to pat on the back to get the fluid moving around.

The residents Routine/PRN treatments include:

- Acetaminophen (Dye-free) 180mg (5.63mls) Q4H PRN

- Fluticasone propionate (Flovent) 50mcg/puff; 1 Puff via Aerochamber/spacer Bid

- Clonazepam 0.04mg (0.4mls) Tid- Ranitidine (Zantac) 45mg (3mls) Bid- Baclofen 10mg Bid + 15mg HS Prn- Lamotrigine 75mg Bid- Polyethylene Glycol (PEG) 3350 Powder –

Standardized dose given once daily- Azithromycin (Zithromax) 65mg (1.63mls)

given once daily for 3 days- Salbutamol (Ventolin) 5 puffs

(100mcg/puff) MDI given via Aerochamber Q2-4H PRN

- Midazolam 2.5mg (0.5mls) PRN

** All medications are given via G-tube with 20 ml flushes before and after**

Preferred ways to learn: Client is only 2 years old and communicates mostly with extra-linguistic factors. Client cries when he wants something, and he is unable to speak or move his arms in a coordinate manner to communicate.

Barriers to learning: Barriers include the client’s inability to communicate/learn because of dystonic episodes secondary to his CP.

Topics to teach: The teaching is mostly directed towards the client’s parents, as they are his primary caregivers.


to discharge the client unless this issues resolve.

Appropriate Referrals Needed To Other Members Of The Health Care Team

An appropriate referral needed to other members of the health care team would be to

physiotherapy to assist the client with rehabilitation to promote strength in his upper body.

Client Teaching for Discharge

The client will not be discharged; therefore, client teaching for discharge is not applicable. The client

will not be discharged because his conditions are too debilitating, and home care/support is not a

reasonable solution. Also, the client does not have family that could provide the safe and advanced

care he needs. At this time the client is being shipped to Vancouver General Hospital where advance

life supports will be applied. Hopefully discharge planning can be implemented thereafter.

Lab and Diagnostics

**October 30/ 2017 Blood Work was discussed in Immune/Hematopoietic assessment**

October 30th 2017 Reference Ranges

WBC 11.3 4.0-10.0

RBC 4.40 4.30-5.50

Hgb 122 135-170

Hct 0.37 0.40-0.49

MCV 83.4 82.0-100.0

MCH 27.7 27.0-34.0

MCHC 332 320-360

RDW 13.4 11.6-15.0

Lymph Auto 3.90 1.00-3.30

CO2 24 22-29

Albumin Lvl 24 35-52


**October 30th/ 2017 Creatinine and GFR levels were discussed in Renal/ Metabolic October 30th 2017 Reference Ranges

Urea 3.9 3.0-8.0

Creatinine 13 45-84

GFR 57 >=60

Sodium Lvl 135 136-145

Potassium Lvl 7.3 3.5-5.1

Date: Oct 30th/2017

Patient initials: Timmy



CURRENT MEDICATIONS (ROUTINE AND P.R.N.)

Generic name/Trade name:

Acetaminophen/Tylenol Ranitidine/Zantac Clonazepam

Classification: Non-Opioid Analgesic & Antipyretic

H2 (histamine-2) Blocker

Benzodiazepine

Dosage/route/frequency ordered:

180mg (5.63mls) Q4H PRN

45mg (3mls) Bid Via G-Tube

0.04mg (0.4mls) Tid Via G-Tube

Why is this client receiving this medication?

Recurrent pain related to CP & dystonic episodes (Deglin, Vallerand, & Sanoski, 2013, pp. 98-99;

Lilley, Harrington & Snyder, 2011).

Client is receiving treatment to alleviate his digestive reflex, and to as a preventative measure of regurgitation (Pediatric Drug Dosage Guidelines, 2012, p. 253).

This medication is being used to

control the client’s seizure activity (Lilley, Harrington & Snyder, 2011).

How does this medication work?

Inhibit an enzyme called, prostaglandins. Prostaglandins cause pain and inflammation after cell injury. It elevates body temperature by affecting the heat-regulating center of the brain known as, hypothalamus. By blocking prostaglandins being produced in the central/peripheral nervous systems, non- opioid analgesics reduce both fever and inflammation (Deglin, Vallerand, & Sanoski, 2013, pp. 98-99;

Lilley, Harrington & Snyder, 2011).

Inhibits the histamine action at histamine 2 receptors of gastric parietal cells (Nursing Drug Handbook, 2015, pp. 1036-1037).

This medication depresses all levels of the

CNS including nerve impulse transmission in motor cortex. Suppresses abnormal

discharge in petit mal seizures

(Nursing Drug Handbook, 2015,

pp. 271-272).

Common side effects include: rash, nausea, stomach pain, itchiness, loss of appetite, dark urine, clay-colour stools and jaundice (Deglin,

Although there are no known side effects of Ranitidine, it is still to be used with caution in renal/hepatic impairment, elderly, or

Side effects include mild, transient drowsiness, ataxia, behavioural

CURRENT MEDICATIONS (ROUTINE AND P.R.N.)

Generic name/Trade name: Baclofen/LioresalFluticasone

Propionate/Flovent Salbutamol/Ventolin

Classification:Gamma-aminobutyric

acid “GABA”Glucocorticoid steroids

Bronchodilator - β2-adrenergic

agonist

Dosage/route/frequency ordered:

20mg/orally tid 50mcg/Puff; 1 Puff Via

Aerochamber/Spacer Bid

5 Puffs (100mcg/puff) MDI

Q2-4H PRN

Why is this client receiving this medication?

This medication blocks the activity of nerves within the part

of the brain that controls the

contraction and relaxation of skeletal

muscle (Lilley, Harrington & Snyder,

2011).

This client is receiving this medication to relieve his seasonal/perennial allergic rhinitis.

The client is receiving this medication to open his airways in order to clear his thick oral secretions, as he needs it. Oral suctioning has been applied periodically afterwards to assist with clearing these secretions.

How does this medication work?

Baclofen works by inhibiting both

monosynaptic and polysynaptic reflexes

at the spinal level, possibly by

hyperpolarization of afferent terminals, although actions at

supraspinal sites may also occur and contribute to its

clinical effect (Lilley, Harrington & Snyder,

2011).

Flovent controls the rate of protein synthesis, depresses migration of polymorphonuclear leukocytes, reverses capillary permeability, and stabilizes lysosomal membranes (Nursing Drug Handbook, 2015, pp. 510-511).

Simulates beta2-adrenergic receptors in lungs, resulting in relaxation of bronchial smooth muscle (Nursing Drug Handbook, 2015, p. 1085).

Common side effects include: confusion,

dizziness, nausea, and unusual weakness

(Lilley, Harrington & Snyder, 2011).

The most common side effects include hot flashes, decreased libido, diarrhea, generalized pain, asthenia, constipation,

Most common reported side effects include headache. Occasional side effects include


NursingDiagnosis #1

Goal NursingInterventions

Rationale Evaluation

Impaired skin integrity related to lack of mobility as evidenced by impaired physical mobility secondary to dystonic episodes, CP, and neurodegenerative disease.

- Client will not develop skin breakdown during his stay at the hospital.

- Client will not exhibit any signs of skin breakdown.

- Assess and clean between skin folds.

- Client’s parents will be educated on the importance of proper fluid and food intake (Jarvis. 2012).

- Client’s parents will be educated on the importance of keeping the skin clean and dry (Jarvis, 2012).

- The client will be repositioned frequently (Jarvis, 2012).

- The client’s skin will be monitored for color or texture changes, or lesions (Jarvis, 2012).

- To prevent break down of skin (Lewis et al., 2014)

- Nutrition helps with the normal cellular integrity and tissue repair (Jarvis, 2012).

- If the skin sits in constant moisture it will soften the skin and causes a break in the skin integrity (Jarvis, 2012).

- Positioning the client helps reduce pressure and shear force to the skin (Jarvis, 2012).

- Regular inspection of the skin can identify problems early (Lewis et al., 2014)

- Reinforce the importance of mobility, turning, or ambulation in prevention of skin breakdown (Jarvis, 2012).

- When doing morning care assess client for signs of skin breakdown.

- The client’s parents will understand why it is important to keep skin clean and dry (Jarvis, 2012).

Discussion of Pathophysiology and Rationale for Nursing Diagnosis


The client has impaired mobility and is unable to walk due to his dystonic episodes secondary

to his CP. When there is constant pressure on parts of the body due to immobility they are at risk for

impaired skin integrity. The skin is broken down easily when its circulation becomes impaired and cell

regeneration is reduced. Blood supply is reduced in places where bony projections are close to the skin

and there is little fatty or muscular tissue to cushion the weight of the body (Gould & Dyer, 2011).

Thus, will cause pressure ulcers. Pressure ulcers are difficult to heal. The skin will become red and

inflamed when pressure ulcers first start, ulceration will follow. To prevent impaired skin integrity,

using sheepskin pads or floatation devices should protect the client’s skin. The client’s position should

be changed frequently to avoid prolonged pressure of the skin. This allows adequate circulation (Gould

& Dyer, 2011). Throughout the three-day assessment the client was rotated from side to side with

pillows to prevent prolonged pressure on his skin. It is important that client education is provided and

directed towards the parents as the client himself is too young to understand.

NursingDiagnosis #2



- Acute Pain R/T teething (Gordon, 2010, p. 277).

- Client will receive adequate pain management for teething.

- Client will remain free of pain during his entire duration at the hospital.

- Educate the parents on using cold applications for pain relief.

- Educate parents on how to manage pain using Acetaminophen

- Educate parents on how to observe for signs of discomfort.

- Promote touching, cuddling, and stroking of the infant.

- The cold compress causes vasoconstriction which reduces blood flow and results in decrease of the nerve fibres being triggered by the pain stimuli (Chow et al., 2013).

- This allows the parents to use appropriate measures before their child’s pain becomes to unmanaged, and

The family will demonstrate an adequate knowledge and understanding of their child’s pain and how to manage it. The infant will continue to have his pain managed and have no pain due to teething. If Timmy experiences pain his parents will be encouraged to use one of the pain management techniques. The nurse will also take


teaches them the appropriate dosage, routes and medications to use (Chow et al., 2013).

- This will allow the parents to observe and adequately deal with their child’s pain (Chow et al., 2013).

- Promotes security for the child and is a form of distraction (Chow et al., 2013).

time to re-educate the parents and address gaps in their understanding of managing Timmy’s pain due to teething.


Acute pain can be described as “pain that is associated with a rapid onset of varying intensity,”

and it is usually an indication of tissue damage, for example teething is a form of tissue damage, due to

the teeth pushing through the gums (Chow et al., 2013, p. 1087). Teething then results inflammation,

discomfort and fever in the infant (Chow et al., 2013).

NursingDiagnosis #3



- Risk for Infection (sepsis) related to the development of opportunistic infections as evidence by client’s built-up resistance to methicillin antibiotics (MRSA)

- The client will remain free from infections as evidenced by negative results of cultured specimens during his entire duration at the hospital.

- Follow appropriate precautions established to prevent transmission of infection. This includes teaching the parents about precautions (Myers, 2014).

- Avoid invasive procedures whenever possible, if they are

- By following the appropriate precautions (i.e: gown, gloves, mask, etc…) when providing care will prevent further infections from developing and will lessen the risk of opportunistic infections from developing (Myers, 2014).

- This client currently has regular blood work done.

- This client currently has a urine analysis done prn.

- Client’s vital signs are normal and kept within a


- Maintain client’s current mental status.

- Pulse will remain within normal limits throughout client’s duration at hospital.

necessary, then perform them using sterile technique.

- Will monitor blood pressure and pulse and document it in client’s chart (Jarvis, 2012).

-Will document presence and quality of central and peripheral pulses in client’s chart (Jarvis, 2012).

- Will assess client’s skin for color, moisture, temperature, and cap refill and document in their chart (Jarvis, 2012).

- Will complete routine vitals every 4 hours as ordered, and document in their chart (Jarvis, 2012).

- Monitoring vital signs helps determine low/high blood pressure, pulse, presence/quality of central/peripheral pulses, and the effects of vasoconstriction. It allows the nurse to see if the client is within a therapeutic range (Jarvis, 2014).

- Pallor, cool/moist skin, and delayed capillary refill may be due to vasoconstriction or a result from cardiac issues (Lewis et al., 2014).

therapeutic range (i.e: blood pressure, pulse, temperature, etc…) (Jarvis, 2012).

- Client’s parents are aware why it is important to keep their son’s vital signs within the normal range (Jarvis, 2012).



There are many things to consider in the development of sepsis. Remick explains “[m]any

cellular aspects become dysfunctional in sepsis and may be characterized as either excessive activation

or depressed function” (para. 20). The client is at risk for sepsis because of his depressed immune

function as a result of his comorbidities’. It is important to continue to monitor the client for signs and

symptoms of sepsis, including increased or decreased body temperature, decreased heart rate, decreased

respiratory rate, increased white blood count, and arterial CO2 tension less than 32 mm Hg (Remick,

2007). Because this client has a greater susceptibility to infections, it is important that infections like

sepsis are identified early on to provide the best possible outcome for the client.

References

British Columbia. (2017). BC guidelines. Retrieved from

Date: Oct 30th/2017

Patient initials: Timmy



www.bcguidelines.ca/pdf/ckd.pdf

Chow, J., Ateah, C. A., Scott, S. D., Scott-Ricci, S., & Kyle, T. (2013). Canadian maternity and

pediatric nursing. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health.

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