NURSING CARE PLAN

ASSESSMENT
Objective: Vital Signs: PR: 116 bpm CR: 119 bpm RR:24 cycles/min BP:100/70 mmhg Temp: 37.5C; afebrile - restlessness noted - irritable - crying - guarding grimaced face - inability to sleep strawberry like tongue

NURSING DIAGNOSIS
Alteration in Comfort related to inflammation of cervical lymph node as evidenced by restlessness, irritability, crying, guarding, grimaced face, and inability to sleep. Prostaglandin, a pain chemical, together with kinins, is synthesized by cyclooxygenase. Tissue or cell damage can trigger the release of prostaglandins within the site promoting inflammation. It causes irritation in the pain receptors and thus, pain is perceived by the brain.

PLANNING

NURSING INTERVENTION
1. Assess level of pain by observation (crying, grimacing, vocal expressions of pain), using pain assessment scales, and by obtaining relevant pain information from parents about childs expression o pain. Provides information upon which accurate assessments of pain and treatment effectiveness can be based. 2. Subjective assessment by accepting patients description of pain. Acknowledge the pain experience and convey acceptance of patients response to pain. Pain is a subjective experience and cannot be felt by others. 3. Monitor VS To provide baseline data of the patient since there is discrepancies on the vital signs when the patient is in pain. 4. Administer IV gamma globulin and high dose of Aspirin therapy as ordered. Decreases

RATIONALE EVALUATION

inflammatory process, pyrexia, and have analgesic effects. 5. Apply cool cloths to skin, lotion, and soft, loose clothing on child. It decreases skin discomfort. 6. Provide calm activities. A calm activity can help the patient become calm also and helps patientexplore methods for alleviation or control of pain. 1. Provide comfort measures (e.g. back rub, and change of position) These measure aids in the alleviation and control of pain. 2. Encourage diversionary activities such as providing the patient with toys, stickers and pads he can stick them, coloring books and crayons. Diverting patients attention helps reduce his focus on the pain. 3. Keep childs room quiet and semi dark. Promotes rest; darkness decrease eye discomfort caused by conjunctivitis. 4. Disturb child as little as possible; when necessary, handle gently and avoid unnecessary handling.

 Movement causes discomfort. 5. Suggest parent be present when performing procedures to comfort child. The presence of the mother reduces fear of the child and increases cooperation from him. 6. Encourage adequate rest periods and sleep. During pain, rest and sleep may be difficult to achieve since it interferes relaxation.