Sr. No.

Nursing Assessment
Child is having Endotracheal Tube in situ and is on Positive Pressure Ventilation with the help of AMBU.

Nursing Diagnosis
Ineffective breathing pattern r/t loss of consciousness as evidenced by irregular breathing and inability to maintain SpO2 WNL Potential for infection r/t Endotracheal tube in situ Potential for altered gas exchange r/t inappropriate manual breaths delivered and pooling of secretions

Expected Outcome
Child follows a regular breathing pattern Child maintain SpO2 WNL Child maintain adequate tissue oxygenation Child develops no signs of infection

Nursing Intervention Planning

Assess the respiratory status by monitoring the rate and depth of respiration. Put the patient on continuous cardiac monitoring and hourly record the readings. Monitor and record SpO2 Give the child semi-fowlers position Monitor and record Vital signs q 1hly Nebulize the child as prescribed

Evaluation

Implementation
Assessed the rate and depth of respiration and recorded them SpO2 :89% every two hourly. No e/o excess Patient is on continuous SpO2 ET secretion or infection monitoring and it is recorded hourly Child is given semi-fowlers position Vital signs monitored and recorded manually every 2hourly Child is being nebulized 4 hourly Oral and ET suction done as needed.

Perform endotracheal suction as needed Two care givers are available and they are doing AMBU Administer antibiotics as alternatively. prescribed Antibiotics given as Ensure always the prescribed availability of a spare care giver in case of emergency

Sr. No.

Nursing Asessment Child is on continuous insulin infusion and has a Bld.Sugar of 192mg/dl

Nursing Diagnosis Altered body functioning r/t impaired glucose metabolism (IDDM) as evidenced by very high blood glucose levels. Potential for Hypo/ Hperglycemia r/t over/ under medication

Expected Outcome Child maintains Blood Glucose levels within normal limits. Planning

Nursing Intervention

Evaluation

Implementation Blood Glucose level monitored and recorded 1 hly and insulin rate titrared accordingly A new chart is maintained where the blood glucose levels and corresponding rate of insulin infusion is recorded hourly. I/O chart maintained. Urine specific gravity monitored once in every shift. Finger tips punctured for glucose monitoring are closely monitored for any pain or redness. Insulin as well as I/V fluids are administered as prescribed.

Assess the Blood Glucose levels frequently Administer Insulin Infusion as prescribed

Blood Glucose: 220mg/dl Insulin infusion :3 units/hr Insulin dose is titrated hourly according to the sliding scale.

Monitor for signs of Hypo/ Child doesnot Hyperglycemia show any s/s Maintain I/O chart of Hypo/ Hyperglycem Measure Urine Specific ia Gravity regularly Record the blood glucose levels and corresponding rate of insulin infusion hourly. Look for any redness or pain at the finger tips punctured for glucose monitoring.

Sr. No.

Nursing Asessment Chid is kept NPO

Nursing Diagnosis Altered fluid electrolyte balance r/t IDDM as evidenced by altered blood electrolyte levels, Polyuria and signs of moderate dehydration

Expected Outcome Child maintains a normal fluidelectrolyte balance

Nursing Intervention

Evaluation

Planning Assess the childs fluidelectrolyte balance Assess the Serum electrolyte levels Connect the child to a continuous cardiac monitor and closely monitor ECG. Administer fluid as prescribed N/2 DNS 5 ml/kg/hr Look for signs of dehydration Maintain Hourly I/O chart Monitor urine o/p and urine specific gravity frequently Assess the nutritional status of the child daily

Implementation Assess the childs fluidelectrolyte balance I/O chart maintained 2hly Electrolyte levels monitored daily Child is on continuous cardiac monitoring. Vital signs are monitored and recorded every 4 hourly Administered fluid as prescribed (N/2 DNS 150ml/hr) Urine op is measured hourly and urine specific gravity is checked in every shift.

Child is maintaining adequate fluid electrolyte balance

Sr. No.

Nursing Asessment Child is bedridden

Nursing Diagnosis Potential for altered skin integrity r/t bed ridden status Self care deficit r/t LoC.

Expected Outcome Child maintains normal skin integrity Childs personal hygiene is maintained

Nursing Intervention

Evaluation

4.

Planning Assess the skin over potential sites of bed sore

Implementation The childs skin is assessed for any redness, blisters or any other early signs of bed sore

Demonstrate to the parents 2 hly back care and Demonstrated to the parents 2 positioning hly back care and positioning Maintain good personal hygiene of the child. Always ensure the linen is dry Avoid pulling the linen under the child which may lead to skin breakdown. Administer high protein diet as prescribed. Demonstrate to the parents bed bath and how to change the childs clothes daily.

Childs personal hygiene is maintained No e/o bed sore

Demonstrated to the parents the technique of changing wet linen while the child is on the bed (Closed bed making) Administered high protein diet as prescribed. Demonstrated to the parents bed bath and how to change the childs clothes daily. Encouraged the parents to do regular back care and change position 2 hourly.

REFERENCES 1. Kliengman and et al; Nelson Textbook of Pediatrics; 18th edition; vol.2; 2404-2429 2. OP Ghai and et al; Ghai Essential Pediatrics; 7th Edition; 434-440 3. Isselbacher et al; Harrisons Principles of Internal Medicine; 16thdition;1252-69 4. Donna L Wong; Essentials of Pediatric Nursing; 5th edition; Pages: 1050-1064. 5. Diabetes Mellitus, Type 1: eMedicine Pediatrics: General Medicine1.mht