Javier, Jomar A.

BSN121 Group 83

Nursing Care Plan

(Pediatric Patient)
Nursing Diagnosis/ Analysis Goal and Intervention Rationale Evaluation
Cues Objectives
Diarrhea r/t Scientific: Goal: Independent: After 4 days of
infectious process Passage of loose, After 4 days of • Restrict solid To allow for bowel nursing
secondary to Acute unformed stools nursing food intake, as rest/reduced interventions, the
Gastroenteritis pathogens cause interventions, the indicated intestinal workload patient
tissue damage and patient will reestablished and
Subjective: inflammation by reestablish and To avoid foods/ maintained normal
• The mother releasing maintain normal • Provide for substances that pattern of bowel
stated “simula endotoxins that pattern of bowel changes in precipitate functioning.
palang nung na stimulate the functioning. dietary intake diarrhea
admit kami dito mucosal lining of • After 1 hour of
nung lunes eh the intestine Objectives: • Limit caffeine discussion, the
nagtatae na resulting in the • After 1 hour of and high fiber It stimulates parent
talaga siya” greater secretion discussion, the foods; avoid gastric motility verbalized
• She also added: of water and parent will milk and fruits, understanding
“naawa na nga electrolytes into verbalize as appropriate causative factor
ako sa kanya the intestinal understanding and rationale
kasi maya’t lumen. The active causative factor for treatment
secretions of and rationale Indicating regimen.
maya ay • Assess for
nagpapalit chloride and for treatment hydration • After 1 hour of
presence of
kami ng diaper, bicarbonate ions regimen. discussion, the
postural
baka nga are the small bowel • After 1 hour of parent
hypotension,
magka- leads to the discussion, the demonstrated
tachycardia,
irritation siya inhibition of parent will appropriate
skin
sap wet dahil sodium re- demonstrate behavior to
hydration/turgo
dun” absorption. To appropriate assist with
r, condition of
balance the excess behavior to resolution of
• “Umiiyak siya mucous
sodium, large assist with causative
minsan at membranes
amounts of protein resolution of factors (e.g.,
nagcocomplain
rich foods fluids are causative To determine proper food
siya na masakit • Weigh infant’s
secreted in the factors (e.g., amount of output preparation, or
tiyan niya” diapers
bowel’s ability to proper food and fluid avoidance of
Objective:
reabsorb the fluid preparation, or replacement needs irritating foods)
• Changed diaper
and leading to avoidance of
3x with loose • Encourage oral
 and deformed diarrhea. irritating foods) intake of fluids
stools containing
• Abdominal Situational: electrolytes,
distention As for the patient, such as juices,
noted upon the causative bouillon, or
palpation factor of her commercial
• Upon diarrhea is her preparation as
auscultation, disease (Acute appropriate.
hyperactive Gastroenteritis) • Assist, as
bowel sounds needed, with
noted. pericare after
• Irritated and each bowel
crying. movement. Because skin
• Provide prompt breakdown can
diaper change occur quickly when
and gentle diarrhea is present.
cleansing

• Apply
lotion/ointment
or petroleum
jelly as skin
barrier, as
needed.
• Provide dry To keep the area
linen, as dry because
necessary. moisture can
adhere skin
• Expose
breakdown
perineum/
buttocks to air;
use heat lamp
with caustion, if
needed.

To promote return
to normal bowel
functioning
• Increase oral
 fluid intake and
return to
normal diet, as
tolerated. Diarrhea maybe
• Encourage result of
nonirritating aggravated by
liquids. intolerance to
• Discuss specific formula.
possible change
in infant To restore normal
formula. flora

• Recommend
products such
as natural fiber,
plain natural
yogurt,
Lactinex.
To prevent
Promote wellness diarrhea from
recurring
• Review
causative
factors and
appropriate
interventions.
• Evaluate/identif
y individual
To prevent
stress factors
bacterial growth/
and coping
contamination
behavior.
• Review food
preparation,
emphasizing
To prevent spread
adequate
infectious causes
cooking time
of diarrhea such as
and proper
C. defficile or S.
refrigeration/st
aureus
 orage.
• Emphasize the
importance of
hand washing. Therapies can
include treatment
Dependent: of fever, pain, and
• Assist in infectious toxic
treatment of agents,
underlying rehydration, and
conditions (e.g., oral feeding, etc.
infections,
malabsorption
syndrome, and
cancer) and
complications
of diarrhea.
• Review
laboratory
studies for To decrease
abnormalities. gastrointestinal
• Administer motility and
enteral and IV minimize fluid
fluids as losses.
indicated.
• Administer anti-
To treat infectious
diarrheal
process, decrease
medications, as
motility, and/or
indicated
absorb water.

• Administer
medications, as
ordered.
 Nursing Diagnosis/ Analysis Goal and Intervention Rationale Evaluation
Cues Objectives
Impaired oral Goal: Independent:
mucous After 5 days of • Routinely
membrane r/t nursing inspect oral
trauma interventions, the cavity and
patient will show throat for
Subjective:
a decrease in inflammation,
• The mother
state: “Me signs and sores, lesions,
singaw siya sa symptoms as and/or
bibig, minsan noted in defining bleeding.
umiiyak siya characteristics. Determine if
pag patient is
pinpapakain ko Objectives: experiencing
siya at minsan • After 2 hours pain or painful To prevent dry
dinudura niya of discussion, swallowing. mouth and
at umiiyak” dehydration.
the parent will • Encourage
Objective:
verbalize adequate
• Single
ulceration on understanding fluids.
the mucosal of causative To reduce
wall noted. factors. discomfort/
After 2 hours of • Provide improve intake
discussion, the dietary and promote
parent will modifications healing
demonstrate (e.g., food of
techniques to comfortable
restore/maintain texture,
integrity of oral temperature,
density) and
mucosa.
adequate
nutrients and
vitamins.
• Avoid
irritating
foods/fluids,
temperature
extremes;
provide soft or
pureed diet as
required. To correct
• Assist/ provide deficiencies and
oral care, as encourage proper
indicated. care.
• Review
current oral
hygiene
patterns and
provide Encourage early
information initiation of good
about oral oral health
health as practice and
required/desir timely
ed. intervention for
• Instruct treatable
parents in oral problems.
hygiene
techniques
and proper
dental care
for
infants/childre
 n (e.g., use of
pacifier,
brushing of
teeth and
gums, Altered immune
avoidance of response can
teeth and affect the oral
gums, mucosa.
avoidance of
sweet drinks To correct
and candy, deficiencies,
recognition reduce irritation/
and treatment gum disease,
of thrush.) prevent dental
• Promote carries.
general/
mental health.
To prevent bottle
• Provide syndrome with
nutrional decaying of
information. teeth.

• Stress
importance of
limiting night When infection is
time regimen present
of bottle of
milk for infant
in bed.
Suggest
pacifier or use
of water
during night.
Dependent:
• Administer
antibiotics, as
ordered
• Review
information
regarding
drug
regimen , use
of local
anesthetics.