nursing care plan

Nursing Care Plan

Nutrition imbalanced less than body requirements related to inadequate food intake

Delayed growth and development: language r/t inadequate stimulation.

Knowledge deficit related to cognitive limitation as evidence by questions and statements of concern

Risk for injury related to sudden, abnormal, and excessive electrical discharges from the brain.

Risk for aspiration related to sudden, abnormal, and excessive electrical discharges from the brain.

Ineffective Family Coping related to Seasonal Work


Subjective: -“saging lang iya ginakaon”as verbalized by the mother.

Objective: Weight: 10.3 kgHeight: 32 inchesBMi: 16.6 (underweight) Hgb=127(dehydration)dry and blonde hairpale conjunctivairritable restless

Assessment

NCP


After 2-3 hours of nursing intervention: The mother will verbalize understanding of nutritional needsThe mother will demonstrate selection or meals that will achieve a cessation of weight loss.

Planning

NCP


Nursing Intervention Nursing Interventions (Independent

and Dependent)Rationale

IndependentDocument actual weight and height.

Obtain nutritional history

Monitor or explore attitudes toward eating and food.Advice the mother to serve food and fluids those are appealing to the client.

IndependentPatient mother may be unaware of the actual height and weight loss of his child due to estimating weight.Patient Mother perception of actual intake may differProper assessment guides informationTo stimulate appetite and promote interest in eating.

NCP




TherapeuticDiscourage beverages that are caffeinated or carbonated.Engage the patient to a healthy physical activities

TherapeuticThese may decrease appetite and lead to early satiety.Metabolism and utilization of nutrients are enhanced by activity.

NCP


Evaluation After 2-3 hours of nursing intervention: The mother verbalized understanding her son’s nutritional needs.The mother made a resolve to prepare nutritious yet affordable food or meals.

NCP


Subjective: “Bale Mama, Papa, Dede kag Wewe palng sina iya namitlangan gha”as verbalized by the mother. Objective:3 year-old older sibling.Lack of time by the mother.Pointing on something he wants.

Assessment

NCP


Within the hospitalization days the patient will achieve realistic developmental and growth milestone based on existing abilities, extent of disability, and functional age.

Planning

NCP




Provide meaningful stimulation by initiating conversation to the client.

Engage the child in appropriate play activities and offer them the appropriate toys.

Enlist and encourage involvement of the parents and/or family as participants in the care of the child particularly in the hospital.

Initiating a conversation is a type of stimulation and it is essential to the development of the language of the child.Play is essential for learning in children and it is also a means of communicating to them.Frequent and consistent family contact and care promotes emotional assurance to the child and thus promotes conversation.

NCP




Provide emotional support for family members in their reactions to evidence of developmental delay.Instruct the mother with regard to age-appropriate activities and play, nutrition, discipline, and safety, and hoe to support growth and development.

Parents may be distress by the potential for development delay of the child.Parents are then better equipped to promote the growth and development of the child.

NCP


Evaluation Goal was not met. The patient still unable to utter other words beside Mama, Papa, wewe, and dede.

NCP


Subjective: “Ano inang seizure nga gina tawag nila man?” as verbalized by the mother.

Assessment

NCP


After 3-4 hours of nursing intervention: The mother can verbalize understanding of disorder and various stimuli that may increase seizure activity.The mother can express a desire for necessary lifestyle/behavior changes as indicated.

Planning

NCP




IndependentDiscuss the pathology/ prognosis of condition and lifestyle need for treatment as indicated.

Discuss patient particular trigger factors (e.g. flashing lights, hyperventilation, loud noises, and video games. And Explain the importance of maintain good general health.

Emphasize the importance of good oral hygiene and regular dental care.

Provides opportunity to clarify/dispel misconception and present condition as something that is manageable within a normal lifestyle.Regularity and moderation in activities may aid in reducing/ controlling precipitate factors, enhancing sense of general well being, and strengthening coping ability and self esteem.Reduces risk of oral infections and gingival hyperplasia.

NCP


Evaluation

Goal met After 3-4 hours of nursing intervention: The mother verbalized understanding of disorder and various stimuli that may increase seizure activity.The mother expressed a desire for necessary lifestyle/behavior changes as indicated.

NCP


Subjective: “Gin hilanat siya kag nag turong iya mata” as verbalized by the mother.

Objective: History of seizure episodes.

Assessment

NCP


The patient will be free from injury within the succeeding days of hospitalization as manifested by:Intact skinNo pain, bruises or fractures present.No limitation in movement.

Planning

NCP




Independent:Seizure precautions

Prepare a tongue depressor at bedsidePad the side of the crib w/ blankets or pillows.Maintain bed in lowest position with wheels locked.Turn head to side.Encouraged bed rest.

A tongue depressor will prevent oral trauma.To avoid patient from injury and promote safety.To promote client safety.

To maintain patent airway.To prevent fatigue and promote healing.

NCP




During the seizure Remain w/ patient. Observe for, record, and

report type, duration, and characteristic of seizure activity and any post seizure response.

Do not restraint the patient but rather guide patient movements gently.

Roll patient into a side-lying position. Used head-chin-lift maneuver.

Loosen tight clothing.

Seizure activity should be documented in detail to aid in management and differentiation of seizure type and identifying of triggering factors. Characteristic of seizure and post seizure response should include, as appropriate, precipitating event, aura, initial location and progression.To prevent injury caused by flailing.

To maintain patent airway.To prevent injury caused by constrictive clothing.

NCP




Dependent Administer Phenobarbital 5mg/pptab

1pptab q 12 hours as ordered by the physician.

Monitor complete blood count, electrolytes and glucose levels.

May be given in emergent situation to potentiate/enhance affects of other Anti-epileptic drugs, and allow for lower dosage to reduce side effects.May be given in emergent situation to potentiate/enhance affects of other Anti-epileptic drugs, and allow for lower dosage to reduce side effects.

NCP


Evaluation Goal met As manifested by : Intact skin No pain, bruises or fractures present.No limitation in movement.

NCP


Subjective: “ Gin hilanat siya kag nag turong iya mata” as verbalized by the mother.

Objective :

History of seizure episodes.

Assessment

NCP


The patient will be free from aspiration within the succeeding days of hospitalization as manifested By:Noiseless respirationsClear breath soundsNo secretion noted.

Planning

NCP




Independent :Elevate client to highest or best possible position for eating and drinking.(high fowlers position)Assess pulmonary status for clinical sign of aspiration. Auscultate breath sounds for development of crackles and/ wheezes.

Provide soft foods.

To reduce risk For aspiration.

Aspiration of small amounts can occur w/o coughing or sudden onset of respiratory distress, especially in patients w/ a decreased level of consciousnessTo prevent aspiration.

NCP


Evaluation Goal met As manifested by:NoiselessRespirations Clear breath soundsNo secretions noted

NCP


Subjective: “Wala permanente nga ubra akon bana. Kulang pa gid sa amon iya sweldo. Housewife man lang ko.” As verbalized by the mother.

Objective:Monthly income is below P5,000

Assessment

NCP


After 2 hours of Nursing intervention, the family should be able to express understanding of the problem and identify resources.

Planning

NCP




Assess family members’ perception of problem. Resolution is possible only if each person’s perception is understood.Evaluate strengths coping skills, and current support systems.

Provide opportunities to express concerns, fears, expectations, or questions.

Depending on the stressor, a variety of strategies may be required to facilitate coping.

This facilitates the use of previously successful techniques.This promotes communication and support.

NCP


Evaluation Goal met.The family was able to express and understand the problem and identified resources.

nursing care plan

Documents

ncp delayed growth

ncp knowledge deficit

body requirements

development delay

growth milestone

affordable food

hours of nursing intervention

type of stimulation