Nursing 620C: Pediatric Care Plan

Patient History
D. G. is an eleven month old girl who was admitted with right lower lobe Pneumonia with a secondary diagnosis of dehydration. She has a past medical history of suspected Neurofibromatosis due to the multiple café au lait spots covering her body. Her mother complained of a fever for nearly three days reaching temperatures around 103 degrees. Other complaints include: a cough, bilateral eye discharge, a runny nose, decreased appetite, and vomiting. She has been placed on Rocefin to kill what might be causing her Pneumonia, and also Lactinex to enhance her normal flora which is being killed by the Rocefin. She had an IV infusing D 5 ¼ normal saline running at 45 ml/hr. Her mother stayed with her while in the hospital.

Upon assessment, D.G.’s vitals consisted of a temperature of 98.1 degrees, a pulse of 130, a respiratory rate of 26, and a blood pressure of 100/75. Her weight was documented at 17 pounds and 13.4 ounces which was about 7 ounces more than she had weighed the previous day. She appeared to be resting comfortably in her mothers arms, and when placed in the crib, also appeared to be resting comfortably.

She appeared very pale for her ethnicity and looked like she had not been feeling well. She had a radial and pedal pulse along with color, sensation and movement bilaterally. Capillary refill time was measured as less than three seconds, and had no edema. She was awake and alert, and only became agitated upon being assessed, but was easily consoled by her mother. Her Oxygen saturation was documented at 100% on room air. Although she did not experience any dyspnea or labored respirations, upon assessing her lung sounds, Rhonchi was heard scattered throughout. She had scant, clear sputum or secretions assessed upon bulb suctioning and was on no respiratory treatments.

Her appetite was poor, although she had been drinking some Pedialyte and Good Start formula. D.G. experienced no nausea or vomiting, but did experience two episodes of diarrhea. She had bowel sounds present in all four quadrants, and her abdomen was soft and non-distended. D.G. was voiding clear, yellow, quantity sufficient urine. She had full range of motion with no casts and was being held by her mother through most of the shift. Skin was warm, dry and intact aside from the café au lait spots on her body.

Nursing Diagnoses
The following nursing diagnoses have been developed for D.G. in relation to her current health status:
1. Risk for impaired gas exchange related to exudates accumulation and increased mucous production
2. High risk for fluid volume deficit related to fluid loss through hyperthermia or hyperpnea (or both)
3. Ineffective airway clearance related to inflammation
4. Ineffective breathing pattern related to an inflammatory infection in the lower airway
5. Acute pain related to infiltration of IV
6. Risk for infection related to inadequate primary defenses
7. Altered nutrition: less than body requirements related to increased metabolic needs
8. Knowledge deficit or parents related to unfamiliarity of the disease process, complications, measures to control it and prevent its transmission

Impaired Gas Exchange
Assessment
Through assessment, the following information was gathered in relation to the diagnosis:
Subjective Information:
-D.G.’s mother states that she looks and feels much better than the previous day
-Mother states that D.G. has not been coughing as much
-D.G.’s mother says that she has been sleeping better and is more relaxed

Objective Information:
-The patient does not look as though she is having difficulty breathing
-Lung sounds have Rhonchi scattered throughout
-There is no use of accessory muscles in breathing
-Oxygen saturation is measured at 100% on room air
-Respiratory rate is 26 which is within normal limits for D.G.’s age
-D.G. has scant amounts of clear sputum and/or secretions
-D.G. hardly needs to be suctioned
-D.G. appears tired and lacking in energy

Goals
Short Term Goal:
The short term goal for D.G.’s diagnosis of impaired gas exchange is that she will have an Oxygen saturation greater than 90% and will be able to maintain oral intake by around 11:00 AM on April 4th.

Long Term Goal:
The long term goal for D.G. in relation to her diagnosis is that D.G. will have an improved gas exchange evidenced by the ease of respirations, improved skin color, and decreased restlessness by around 6:00 PM on April 4th.

Nursing Interventions:
1. Intervention: Assess respiratory status
Rationale: Indicates if treatment is effective or if condition is worsening (Speer 24)
Outcome: The child will have no abnormal results in a respiratory assessment
2. Intervention: Auscultate breath sounds every 2-4 hours
Rationale: Decreased or adventitious breath sounds signal potential airway obstruction that could further aggravate hypoxia and necessitate prompt intervention (Swearingen 124)
Outcome: Breath sounds will be evident and without any adventitious sounds
3. Intervention: Observe for and promptly report signs of respiratory distress
Rationale: These signs of respiratory distress including restlessness, anxiety, changes in mental status, shortness of breath, tachypnea and the use of accessory muscles represent the need for medical intervention (Swearingen 124)
Outcome: The child will show no signs of respiratory distress
4. Intervention: Monitor and document vital signs every 2-4 hours
Rationale: A rising temperature or changes in vital signs may signal the presense of worsening inflammation response in the lungs (Swearingen 124)
Outcome: Vital signs will be monitored every 2-4 hours and will remain within the normal limits
5. Intervention: Monitor oximetry readings and report an Oxygen saturation of 90% or less
Rationale: An Oxygen saturation of 90% or less is a significant sign of an oxygenation problem that can indicate the need for Oxygen therapy (Swearingen 125)
Outcome: The child's Oxygen saturation will remain at about 95%
6. Intervention: Encourage oral intake of fluids
Rationale: Fluids generally liquify secretions (Speer 25)
Outcome: Patient will be taking oral fluids every 1-2 hours
7. Intervention: Administer antibiotics as prescribed
Rationale: Decreases the inflammation response in the lungs to promote healing and decrease the risk of mortality (Swearingen 124)
Outcome: Antibiotics will be administered as prescribed
8. Intervention: Provide frequent rest periods
Rationale: Rest is necessary to conserve energy to fight infection (Speer 25)
Outcome: Patient will rest frequently throughout the day
9. Intervention: Suction as needed
Rationale: Maintains airway patency (Speer 24)
Outcome: Patient will be suctioned as appropriate
10. Intervention: Ensure the availability of emergency equipment
Rationale: Basic emergency preparedness (Newfield 348)
Outcome: Emergency equipment will be available at the bed side in the event of an emergency
11. Intervention: Provide for parental or caregiver input in planning and implementing care as far as comfort measures, daily hygiene and feeding are concerned
Rationale: Parental involvement provides emotional security for children and allows parents or caregivers to practice care techniques in a supportive environment (Newfield 348)
Outcome: Caregivers will take part in child's care by assisting in hygiene, feeding and comfort
12. Intervention: Allow for the parents or caregivers to verbalize concerns about the child's health status and changes while encouraging them to ask questions
Rationale: Decreases anxiety and provides a teaching opportunity (Newfield 348)
Outcome: Caregivers will ask questions and voice any concerns or misunderstanding about the child's condition

Outcome
Through implementing the nursing interventions above, D.G. was both cooperative and responsive. D.G.’s mother stayed involved in her care throughout every procedure and was very attentive to her needs. After having implemented these interventions, D.G.’s lung sounds had rhonchi scattered throughout, but without any signs of dyspnea. All vital signs remained within normal parameters and Oxygen saturation was documented at 100% on room air. D.G. was placed in her crib to nap a few times during the day, but was otherwise held by her mother. D.G. was also able to maintain an oral intake that was not as high as the nurses would have liked to have seen, but was in fact taking oral fluids. D.G.’s mother states that’s he is looking and feeling much better than she had the past few days in the hospital.

Evaluation
The short term goal for D.G. was met well before 11:00AM on April 4th. Her Oxygen saturation remained at 100% throughout the day and she was able to maintain her oral intake. It appears that the nursing interventions implemented greatly increased D.G.’s ability to keep her intake in her system, and also allowed her a better respiratory status than she may have previously had.

The long term goal for D.G., evaluation was set for around 6:00PM on April 4th. The client has made some progress towards this goal evidenced by her having no difficulty breathing, and being able to relax rather than being restless. Perhaps if fluids were pushed more often, her color would improve, and she would not appear to be so pale, and there would be less rhonchi heard scattered throughout her lungs because the secretions would become more liquefied.

Fluid Volume Deficit
Assessment
Through assessment, the following information was gathered in relation to the diagnosis:
Subjective Information:
-D.G.’s mother states that she is taking more oral fluids than she previously was
-Mother states that D.G. still is not drinking as much as she should be
-Mother states that many times, when she tries to give D.G. her bottle to get her to drink, she -pushes it away and refuses
-Mother states that she looks and feels better than she previously had

Objective Information:
-D.G. looks pale for her ethnicity and looks as though she does not feel well
-Her mucous membranes are moist
-D.G. has good skin turgor
-D.G. has gained weight
-Capillary refill time for D.G. was determined to be less than 3 seconds
-D.G. had two episodes of diarrhea
-D.G. is able to maintain oral intake
-D.G.’s intake and output are nearly balanced
-D.G.’s eyes do not look as though they are sunken in, and her fontanel does not feel sunken

Goals
Short Term Goal:
The short term goal for D.G. in relation to her diagnosis for fluid volume deficit is that she will have good skin turgor, moist mucous membranes and a capillary refill time within 3 to 5 seconds by the time her noon assessment is completed on April 4th.

Long Term Goal:
The long term goal for D.G. is that she will maintain a stable weight and her intake and output will be nearly balanced and within at least 200ml of each other by the end of the day shift which is around 3:00PM on April 4th.

Nursing Interventions:
1. Intervention: Monitor I & O's
Rationale: A decrease in urine output indicates dehydration (Speer 25)
Outcome: I & O's will remain closely balanced
2. Intervention: Assess for an increased respiratory rate and fever every 1-2 hours
Rationale: This is essential in detecting fluid loss, which can increase with an increased respiratory rate and temperature (Speer 25)
Outcome: Respiratory rate and temperature will remain within normal parameters
3. Intervention: Assess for signs of dehydration including poor skin turgor, dry mucous membranes, and sunken fontanels and eyes
Rationale: This intervention detects the need to adjust fluid intake (Speer 25)
Outcome: Patient will demonstrate good skin turgor, moist mucous membranes and no sunken fontanel or eyes
4. Intervention: Encourage fluid intake to a minimum appropriate for the child's age (about 700-1,000 ml/kg in 24 hours)
Rationale: Prompt replacement and maintenance of appropriate fluids prevents further circulatory or systemic problems (Swearingen 163)
Outcome: Patient will be able to drink the appropriate amount of fluids for her age
5. Intervention: Weigh the patient daily at the same time with the same clothing but without a diaper, and on the same scale
Rationale: Weight serves as a major indicator of whether or not treatment is effective (Swearingen 164)
Outcome: The patient's weight will not fluctuate, but will remain at a healthy level
6. Intervention: Maintain IV therapy
Rationale: Ensures adequate hydration status (Newfield 127)
Outcome: IV therapy will be continued and administered as prescribed
7. Intervention: Report any urine output less than 0.5 ml/kg/hr
Rationale: Less than this amount indicates fluid volume deficit (Newfield 126)
Outcome: Patient will have a urine output greater than 0.5 ml/kg/hr

Outcome
Through implementing the nursing interventions above, D.G. was once again, both cooperative and responsive. Her intake and output were closely monitored while fluids were strongly encouraged. D.G. still refused any oral fluids and pushed away her bottle when her mother attempted to get her to drink some more. D.G.’s respiratory rate remained within normal parameters, she demonstrated good skin turgor, a capillary refill time of less than three seconds, moist mucous membranes, a pale skin color for her ethnicity and had no sunken fontanel or eyes. Upon being weighed, it was determined that D.G. was actually gaining back some weight. Her urine output remained within normal parameters and was nearly balanced with her intake.

Evaluation
The short term goal for D.G. was met by noon assessment on April 4th. D.G. demonstrated good skin turgor, moist mucous membranes and a capillary refill time of less than three seconds. If fluids had been encouraged more often, perhaps these goals could have been met much earlier, or during previous days.

The long term goal for D.G. had an evaluation time set for 3:00PM on April 4th. D.G. had made significant progress towards this goal. On her I&O sheet, it was shown that her intake closely matched what her output was, making them nearly balanced. This is always a good sign when assessing a patient’s intake and output.

Overall Evaluation
Overall, it appears as though the nursing interventions that were implemented, were effective in enhancing D.G.’s health status. Before having intervened, D.G. had nursing diagnoses of impaired gas exchange and fluid volume deficit. In acting upon these diagnoses and treating them with specific interventions, D.G. made a significant improvement in becoming a healthier individual like she previously had been. D.G. was able to maintain a better fluid balance which was important in treating her fluid volume deficit, and with the help of the fluids, was able to maintain a somewhat clearer airway than she had. Although her lung sounds did not completely clear, tending to these two nursing diagnoses definitely gave her an advantage in being able to rid her body of Pneumonia. Each intervention implemented had an exact reason behind it, which allowed for a more clear understanding as to why certain tasks or procedures would be performed.

Conclusion
In conclusion, a thorough nursing care plan can meet the needs of any patient, no matter what age, diagnosis or other factors are in place. In developing this care plan, one can clearly organize how to approach caring for a patient with a specific diagnosis. In doing so, the nurse can see which diagnoses rank over others, demonstrating which ones should be treated first, while also giving specific interventions used to approach meeting the goals of the diagnosis. In this specific case, it is clear that the actions of the nurses can greatly influence a child’s health status. In intervening to D.G.’s needs, nurses are able to improve her health status to allow her to return home where she can be better cared for by her mother alone.



References
Jaffe, M. (1998). Pediatric nursing care plans. Colorado: Skidmore-Roth Publishing Inc.
Newfield, S. (2007). Cox’s clinical application of nursing diagnosis: Adult, child, women’s, mental health, gerontic, and home health considerations. Philadelphia: F.A. Davis Company.
Potts, N., Mandleco, B. (2007). Pediatric nursing: Caring for children and their families. United States: Thomson Delmar Learning.
Speer, K. (1994). Pediatric care planning. Springhouse Publishing Company.
Swearingen. (2008). All-in-one care planning resource: Medical-surgical, pediatric, maternity, & psychiatric nursing care plans. United States of America: Mosby Elsevier.