pediatric nursing care (case study)

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1 CASE STUDY PEDIATRIC NURSING CARE IN PATIENT WITH MEDICAL DIAGNOSIS UPPER RESPIRATORY INFECTION AND BILATERAL OTITIS MEDIA BY: GROUP I MIRA UTAMI NINGSIH (130915.216) RAGIL YUNILA (130915.198) AGNES ANITA P. (130915.174) ANSALMUS ORON (130915.233) WIWIN NURMALANTIKA (130915.234) MEI D F DAEL (130915.161) OLIVIA YOSEFINA A. (130915.163) SAKTI RAHAYU (130915.180) LISA HANDAYANI (130915.183) RUFINA HURAI (130915.184) FREDDI RAMANDA D. (130915.199) MUHAMMAD HARIYADI (130915.206) ILMASARI (130915.210) META KAMELUH I.R. (130915.204) RUDI HARIYONO (130915.232) FACULTY OF NURSING AIRLANGGA UNIVERSITY 2009

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Page 1: Pediatric Nursing Care (Case Study)

1

CASE STUDY

PEDIATRIC NURSING CARE IN PATIENT WITH MEDICAL DIAGNOSIS

UPPER RESPIRATORY INFECTION AND BILATERAL OTITIS MEDIA

BY: GROUP I

MIRA UTAMI NINGSIH (130915.216)RAGIL YUNILA (130915.198)AGNES ANITA P. (130915.174)ANSALMUS ORON (130915.233)WIWIN NURMALANTIKA (130915.234)MEI D F DAEL (130915.161)OLIVIA YOSEFINA A. (130915.163)SAKTI RAHAYU (130915.180)LISA HANDAYANI (130915.183)RUFINA HURAI (130915.184)FREDDI RAMANDA D. (130915.199)MUHAMMAD HARIYADI (130915.206)ILMASARI (130915.210)META KAMELUH I.R. (130915.204)RUDI HARIYONO (130915.232)

FACULTY OF NURSING

AIRLANGGA UNIVERSITY

2009

Page 2: Pediatric Nursing Care (Case Study)

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PREFACE

We really grateful to the Most Glorious and the Most Merciful

Allah SWT, we can finished this paper about Pediatric Nursing Care in

Patient with Medical Diagnosis Upper Respiratory Infection and Bilateral

Otitis Media ontime. This paper written as a part of process in studying

English in nursing science and technology.

Our appreciation to Dr. Nursalam, M. Nurs (Hons) as our lecturer

who has generously provided us with constructive criticism and

suggestions to completed this paper. Special thanks to all of our

colleagues in class B 12 who have participated in our seminar discussion

about the case in this paper. We aware that still there are many lack in this

paper so we could use some direction and we always open to your

suggestion to make it better. At last, we hope this paper may brings much

advantages to all of us.

Surabaya, 9th October 2009

Author

Page 3: Pediatric Nursing Care (Case Study)

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CONTENTS

Cover....................................................................................................... i

Preface................................................................................................... ii

Contents................................................................................................. iii

I. Case ...............................................................................................1

II. Pediatric Nursing Care in Patient with Medical Diagnosis Upper

Respiratory Infection and Bilateral Otitis Media...............................2

A. Assessment................................................................................2

B. Data Analysis and Nursing Diagnosis........................................5

C. Nursing Care Plan......................................................................8

D. Implementation.........................................................................18

E. Evaluation ................................................................................26

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I

CASE STUDY

Mrs. King brings 2,5 years-old Billy to the pediatrician’s office

because he has been “irritable and feverish since last night.” Further

history reveals that Billy also had a runny nose and cough for two days,

and that his appetite and fluid intake have decreased since the fever

started. Billy is otherwise healthy, this is the first episodic illness. His

physical examination reveals slight, irritable, 2,5 years-old boy, crying,

pulling at ears, temperature of 1020 F, pulse 100x/minute, respiration rate

35x/minute, nasal congestion with clear discharge, tympanic membranes

red and bulging bilaterally, pharynx slightly red without exudates, difficulty

vocalizing. Chest clear, abdomen soft without hepatosplenomegali (HSM)

and no meningeal sign.

The Pediatrician diagnoses an upper respiratory infection (URI)

and bilateral otitis media (BOM) and order amoxicillin 250 mg t.d.s for 10

days. You the office nurse, are to perform the parent teaching for Billy’s

home care. During your discussion with Mrs. King she tells you that she is

concerned that Billy is jealous of his new baby sister because he has

occasional tantrums when she holds the baby. She is concerned about

Billy development because he recently started to refuse using potty, a skill

that is newly acquired. Mrs. King is very attentive to both new baby and

Billy throughout the interview, and she asks you for suggestions in how to

help Billy cope to the new arrival. While doing so, she points out that her

husband has been extra attentive to Billy since his sister was born.

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II

PEDIATRIC NURSING CARE IN PATIENT WITH MEDICAL DIAGNOSIS

UPPER RESPIRATORY INFECTION AND BILATERAL OTITIS MEDIA

A. ASSESSMENT

1. Patient Identity

Name : “B”

Age : 2,5 years old

Race : Java

Religion : Moslem

Education : -

Address : Mulyorejo, Surabaya

2. History Of Present Illness

- Chief Complain : Feverish since last night

- Present Illness : Client has been irritable and feverish since

last night, he also had a runny nose and

cough for two days.

3. Past Nursing History

- History of contagious diseases : None

- Hereditary Diseases :None

- Allergic history : None

4. Family Health History

Client’s mother said that their family doesn’t have history of

contagious diseases and hereditary diseases

5. Observation and Physical Examination

- Vital Sign :

Temperature: 38,80 C P : 135 x/minute RR : 30 x/menit

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- BI: BREATHING ( Respiratory System)

Complain : Cough (+), Breathing (-), difficulty vocalizing

RR pattern : Frequency 30 x/mnt, Rhythm : Regular

Breathing : wheezing (-), ronchi (-), secret (+), flares nose

(+), hyperemi Faring (+) no exudates, runny

nose (+)

Problem : Ineffective Airway Clearance

- B2: BLEEDING (Cardiovascular System)

Complain : chest pain (-), P = 135 times/minute

Heart sound : Normal

Problem : None

- B3: BRAIN (Nervous System)

Orientation : Person, Time, Place normal

Meningeal sign (-)

Awareness : Composmentis

GCS : E4 V5 M 6

Eye : Pupil Isochors, Light reflex (+)

Conjunctiva : Light red

Problem : None

Ear : Tympani membranes red, bulging bilaterally

Problem : Acute Pain

- B4: BLADDER (Genitourinary System)

Complain  : None

Nocturia  : (-)

Fluid intake : Oral 1000cc/day, Parenteral  : 750 cc/day

Problem : None

- B5: BOWEL (Gastrointestinal System)

Mouth : Pharynx slightly red, Stomatitis(+)

Complain : Abdomen(-),Alvi elimination(-).

Weight : 13 kg High : 100 cm

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Nutrition : Eat 2x/day Portion : 3-5 spoon (half of

portion)

Problem : Altered nutrition; less than body requirement

- B6: BONE (Bone – Muscle – Integument)

Joint Activity : Free

Back Injury : None,

Integuments : Skin feels hot, T: 38,80C

Acral : Warm

Turgor : Excellent

Problem : Hyperthermia

- Psycho-social

Client’s mother said that he is jealous of his new baby

sister because he has occasional tantrums when she holds the

baby. Client’s mother is concerned about client’s development

because he recently started to refuse using potty, a skill that is

newly acquired. Client crying and seems irritable.

- Endocrine System

Complain : None

6. Laboratorium

Blood

• Hb : 11,9

• PLT : 160

• WBC : 13,2

• RBC : 3,00

• PCV : 37,4

Urine : Leukosit : 1-3

7. Radiologi :

Thorax photo Normal

Page 8: Pediatric Nursing Care (Case Study)

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8. Therapy :

• Amoxicillin 250 t.d.s

• Oxymetazoline 2 drop twice a day

• Paracetamol 250mg t.d.s

B. DATA ANALYSIS

DATA ETIOLOGY PROBLEMS

Subjective Data

Client’s mother said

that he has been

irritable and feverish

since last night.

Objective Data

Temperature of

1020 F

Tympanic

membranes red and

bulging bilaterally

Pharynx slightly red

without exudates

Lab test WBC :13,2

K/UL

Increase metabolism

secondary to disease/

infection process

Hypertermia

Subjective:

Client’s mother said

that Billy has been

irritable and feverish

since last night

Objective

Client’s seems irri-

Infection in medial ear

tension in medial ear

press the tympanic

membrane

Acute pain

Page 9: Pediatric Nursing Care (Case Study)

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table, crying

Pulling at ears

tympanic membranes

red and bulging

bilaterally

tympanic membrane

bulging bilaterally

Pain

Subjective:

Client’s mother said

that his appetite and

fluid intake have

decrease since the

fever started.

Client’s mother said

that he only finished

a half of his meals

Objective:

Pharynx slightly red

without exudates

Less appetite and

increased metabolism

secondary to disease

process

Altered nutrition: Risk

for less than body

requirements

Subjective

Client’s mother said

that he had runny

nose and cough two

days.

Objective

Nasal congestion

with clear discharge

The client’s can’t

perform effective

cough

Difficulty vocalizing

Retained secret and

edema of nasal mucous

Ineffective airway

clearance

Page 10: Pediatric Nursing Care (Case Study)

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Subjective Data

Client’s mother said

that Billy is jealous of

his new baby sister

because he has

occasional tantrums

when she holds the

baby

Client’s mother said

that Billy recently

started to refuse

using potty

Sibling complex; The

new arrival in family

Family coping: risk for

growth

C. NURSING DIAGNOSTIC

1. Ineffective airway clearance related to retained secret and edema of

nasal mucous, signed by client’s mother said that he had runny nose

and cough two days, nasal congestion with clear discharge, client

can’t perform effective cough, difficulty vocalizing

2. Acute pain related to increasing of tension in middle ear secondary

to infection process signed by client’s mother said that Billy has been

irritable and feverish since last night, client’s mother said that his

appetite has decrease, client seems irritable, pulling at ears,

tympanic membranes red and bulging bilaterally

3. Hyperthermia related to Increase metabolism secondary to disease/

infection process signed by Client’s mother said that he has been

irritable and feverish since last night, temperature of 1020 F,

tympanic membranes red and bulging bilaterally, pharynx slightly red

without exudates.

4. Altered nutrition: Risk for less than body requirement related to

decreased appetite and the increased metabolism secondary to

disease process signed by client’s mother said that his appetite and

Page 11: Pediatric Nursing Care (Case Study)

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fluid intake have decrease since the fever started, client’s mother

said that he only finished a half of his meals, pharynx slightly red

without exudates

5. Family coping: risk for growth related to sibling complex; the new

arrival in family signed by client’s mother said that Billy is jealous of

his new baby sister because he has occasional tantrums when she

holds the baby, client’s mother said that Billy recently refuse using

potty

C. PLANNING

Dx Expected Outcomes

Nursing Orders Rationale

1 Demonstrate

adequate air

exchange, as

evidence by:

a. Use of correct

breathing/coughi

ng technique

b. Productive

cough

c. Client’s and care

giver know and

understand how

to help client to

maintain patent

airway.

1. Monitoring

respiratory status;

rate, depth

2. Monitoring vital

sign

3. Evaluate amount

and type of secre-

tions being pro-

duce

4. Assess client’s/

caregiver know-

ledge of contri-

buting causes,

treatment plan,

1. Tachypnea is usually

present to some

degree and may be

pronounced during

respiratory stress.

2. Inadequate

oxygenation cause

increased pulse rate.

3. Excessive and/or

sticky mucus can

make it difficult to

maintain effective

airways

4. To determine aduca-

tional needs

Page 12: Pediatric Nursing Care (Case Study)

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specific medica-

tion and thera-

peutic procedures

5. inform client/

caregiver to posi-

tionning client’s

head appropriate

for age and

condition/ disorder

6. inform client or

care giver to

maintain adequate

fluid intake

especially warm

fluid.

7. Administer

prescribed

expectorant,

decongestant or

anti histamine

8. Discuss important

of following the

therapeu-tic

procedure as its

schedule

9. Inform client/

5. Repositioning head

may, at times, be all

that is needed to

open or maintain

open airway in at-rest

or compromised

individual, such as

one with sleep apnea

6. Cold water or fluid

can lower the verge

limit of allergic and

make nasal

congestion worse

7. Expectorant helps

loosen secretions so

they can be coughed

up an wxpelled.

Decongestant and or

anti histamine can

helps reduce mucous

edema and nasal

congestion

8. Discipline in following

the therapeutic

procedure deter-mine

the success of

therapy

9. Knowledge about

Page 13: Pediatric Nursing Care (Case Study)

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caregiver about the

medication

procedure (e.g.,

the use of

medicine, side

effect, schedule,

dosage)

medication can

increase client/care-

giver discipline, avoid

anxiety related to side

effect of medicine

and also determine

the success of

therapy

2 Demonstrate a

decrease in

symptoms/

complaints as note

in defining

characteristic

a. Demonstrate of

relaxation

attitude.

b. Client or care-

giver under-

stand and

demonstrate the

way to reduce

pain

c. Follow

prescribed

pharmacological

regimen

1. Note client’s age/

developmental

level and current

condition (e.g.,

infant/child,

critically ill)

2. Obtain client’s

assessment of pain

to include location,

characteristic,

onset/ duration,

quality, intensitivity.

3. Note possible pa-

thophysiological/

psychological

causes of pain

(e.g., inflammation,

trauma, infection

process)

4. Use pain rating

scale appropriate

for age/ cognition

(e.g., facial

expression/Wong-

1. affecting ability to

report pain

parameters

2. identify precipitating/

aggravating and

relieving factors

3. acute pain which

follows an injury/

trauma or occurs

suddenly with the

onset of painful

condition

4. assessment pain

scale helps to plan

the suitable way to

relieve pain

Page 14: Pediatric Nursing Care (Case Study)

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Baker faces pain

scale for pediatric

or nonverbal,

behavior pain

scale)

5. Observe nonverbal

cues (e.g., how

client walks, holds

body, guarding

behaviors, gri-

macing facial,

narrowed focus;

crying, lethargy in

infant)

6. Monitor vital signs

during episodes of

pain

7. Administer

analgesic to

maximal dosage as

“acceptable” level

of pain and inform

client or caregiver

about the

medication

procedure

8. Teach caregiver to

note the cues of

pain and to

manage comfort for

client

5. identify behaviors that

may indicate pain in

persons who cannot

communicate

verbally. Helpful in

recognizing presence

of pain

6. Blood pressure,

respiratory and heart

rate are usually

altered in acute pain

7. The type of

medication ordered

depends on the type

and severity of pain.

Knowledge of

medication procedure

increase client/

caregiver cooperation

in therapy.

8. For client who cannot

verbalizing pain, the

caregiver should note

the cues of pain to

Page 15: Pediatric Nursing Care (Case Study)

15

9. Teach client or

care-giver to helps

client demonstrate

way to maintain

same pressure in

ear (e.g., promote

swallowing or

yawning)

start manage comfort

to reduce pain and

helps client to

maintain positive

coping against pain

9. Some way (e.g.,

swallowing, yawning)

can cause opening

eustachius tube that

make the same

pressure in ear,

reduce bulging and

pain.

3 Temperature in

normal range as

evidence by:

a. Maintain core

temperature

within normal

range

b. Demonstrate

behaviors to

monitor and

promote

normothermia

c. Client and care-

giver understand

and able to

mention ways to

promote

normothermia

1. Note chronological

and developmental

age of client

2. Monitor core tem-

perature by appro-

priate route

1. Infants, young chil-

dren and elderly

persons are most

susceptible to dama-

ging hyperthermia.

Environmental factors

and relatively minor

infections can pro-

duce a much higher

temperature in infants

and young children

than in older children

and adults

2. To gain valid data

about the presence of

temperature elevation

(>98.6ºF [37ºC]) or

fever (100.4ºF

Page 16: Pediatric Nursing Care (Case Study)

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3. Teach parents how

to measure child’s

temperature, at

what body tempe-

rature to give

antipyretic medica-

tions, and what

symptoms to report

to physician

4. Discuss importance

of adequate fluid

intake at all times

and ways to

improve hydration

status when ill or

when under stress

(e.g., exercise, hot

environment).

[38ºC]).

3. Low grade fever

enhances immune

system functioning in

presence of infection

and is not harmful as

long as individual is

not dehydrated or

susceptible to febrile

seizures. Fever may

be treated at home to

relieve the general

discomfort and

lethargy associated

with fever. Fever is

reportable, however,

especially if it is

unresponsive to

antipyretics and fluids,

because it often

accompanies a

treatable infec-tion

(viral or bacterial)

4. Adequate fluid intake

needs to replace fluids

lost through perspira-

tion and respiration

and to avoid

dehydration

Page 17: Pediatric Nursing Care (Case Study)

17

5. Instruct families/

caregivers (of young

children, persons

who are outdoors in

very hot climate)

dangers of heat ex-

haustion and heat-

stroke and ways to

manage hot envi-

ronments. Instruct

parents to avoid

leaving young chil-

dren in unattended

car

6. Teach client or

caregiver to

promote cooling by

means of:

a. Limiting

clothing/dress in

lightweight,

loose-fitting

clothes.

b. Cool the environ-

ment with air

conditioning or

fans

c. Provide cool/tepid

sponge baths or

immersion if

temperature is

>1040F or local

5. Heat injuries can be

immediately life-

threatening. Being

aware of environ-

mental hazards and

hydration levels can

save one’s life

6. Enable client or

caregiver to promote

cooling.

a. Encourage heat

loss by radiation

and conduction

b. Promotes heat loss

by convection

c. Heat loss by eva-

poration and con-

duction. Note: in

pediatric clients,

tepid water is pre-

Page 18: Pediatric Nursing Care (Case Study)

18

ice packs,

especially in groin

and axille (areas

of high blood

flow)

d. Keep clothing

and linens dry

7. Administer medica-

tions (e.g., dantro-

lene, chlorproma-

zine, or diazepam)

as ordered

ferred. Alcohol

sponge baths are

contraindicated

because they in-

crease peripheral

vascular constrict-

tion and CNS

depression; cold-

water sponges/

immersion can

increase shivering,

producing heat.

d. To reduce

shivering

7. To manage hyper-

thermia, control

shivering and

seizures.

4 Demonstrate un-

derstanding in

avoid altered nutri-

tion; risk for less

than body require-

ments. As eviden-

ce by:

a. Client/ caregiver

verbalizing

understanding

how to keep

adequate

1. Assess client/care-

giver knowledge of

nutritional needs

and ways client is

meeting these

needs.

2. Teach client/care-

giver way to in-

crease appetite:

a. Determine when

client prefers/

tolerates largest

1. Identifies teaching

needs and/or helps

guide choice of

intervention.

2. Increase appetite can

increase the nutrition

intake.

a. To promote sense

of control and give

client opportunity

Page 19: Pediatric Nursing Care (Case Study)

19

nutrition intake

for client

b. Client finished

all of his meal

c. Present weight

in control

meal of the day.

Maintain flexi-

bility in timing of

food intake

b. Provide nume-

rous small feed-

ings, as indica-

ted; supplement

with easily di-

gested snack

c. Encourage va-

riety in food

choice, varying

textures and

taste sensations

(e.g. sweet, sal-

ty, fresh, me-

thods of cook-

ing)

3. Suggest client/care-

giver to increase

specific nutrients

(e.g., protein, carbo-

hydrates, fats and

calories), as need-

ed, providing client

with preferred food

and seasoning

choices where

to eat when

feeling more

rested, less pain

or nausea

b. Reduce feeling of

fullness that can

accompany larger

meals, and to

improve chances

of increasing the

amount of nutri-

ents taken over

24-hour period

c. Enhance food

satisfaction and

stimulate appetite.

3. To enhance intake,

specific nutrients

(e.g., protein, vita-

mins) are needed to

help recovery from

illness or against

infection

Page 20: Pediatric Nursing Care (Case Study)

20

possible

4. Suggest client/care-

giver to promote

adequate/timely

fluid intake

4. Fluid is essential to

the digestive process

and is often taken

with meals. Fluids

may need to be

withheld before meals

or with meals if

interfering with food

intake

5 Client/caregiver

Demonstrate

effective family

coping

Outcome criteria:

a. Client/ family

can verbalize

the way to cope

the situation

b. Family/parents

verbalizing their

understanding

of growth

process in

toddler

1. Discuss family

perceptions of

situation

2. Identify current be-

haviors of the family

members (e.g., ig-

noring/ caring client

at home; anger and

ways of touching

between family

members, care

expressions)

3. Suggest family to

involve client in

taking care of the

new baby

1. Expectation of client

and family members

may/may not be

realistic and may

interfere with ability to

deal with situation

2. Indicators of extent of

problems existing with-

in family. Relation-

ships among family

members before and

after current new born

affect ability to deal

with problems of

caretaking

3. Getting involve in

taking care of the new

baby help client to find

his new role in family

as a brother and also

Page 21: Pediatric Nursing Care (Case Study)

21

4. Suggest family to

give the same

attention and care

to both client and

the new baby

5. Explain family about

toddler growth

6. Explain family/ pa-

rents about the

importance of deve-

loping good com-

munication between

parents and child

feels posses

4. Same attention and

care help to avoid

jealousy

5. Helping family/ parents

to take care of client

appropriate to client

growth.

6. Good communication

make it easier for

family to teach client

skill that is appropriate

to his growth (e.g.,

using potty)

D. IMPLEMENTING

Nursing diagnosis Implementation Respond

1. Ineffective air-

way clearance

related to re-

tained secret and

edema of nasal

mucous

1. Monitoring respiratory

status; rate, depth

2. Monitoring vital sign

3. Evaluating amount

1. Respiration rate 35x/

minute. Difficulty in

respiration because of

nasal congestion with

clear discharge. Client

has runny nose

2. RR: 35x/minute, pulse:

100x/minute,

temperature: 1020 F

3. Clear discharge from

Page 22: Pediatric Nursing Care (Case Study)

22

and type of secretions

being produce.

4. Assessing client/care-

giver knowledge of

contributing causes,

treatment plan,

specific medication

and therapeutic

procedures

5. informing client/care-

giver to positioning

client’s head appro-

priate for age and

condition/ disorder

6. informing client or

caregiver to maintain

adequate fluid intake

especially warm fluid.

7. Administering pres-

cribed expectorant,

de-congestant or anti

histamine

8. Discussing important

of following the

therapeutic procedure

as it scheduled

9. Informing client/care-

giver about the

medication procedure

nasal. Client cannot

expel the secretion by

coughing it up

4. Client’s parents said

that they really concern

about client condition

and don’t know about

the medication

5. Client’s parents said

that they understand

and will follow the

suggestion

6. Client’s parents said

that they understand

and will follow the

suggestion

7. Client is given Oxyme-

tazolone 2 drops twice

a day

8. Client’s parents said

that they understand

and will maintain their

child to follow the

therapeutic procedure

as it scheduled

9. Client’s parents said

that they understand of

information that has

Page 23: Pediatric Nursing Care (Case Study)

23

(e.g., the use of

medicine, side effect,

schedule, dosage)

given.

2. Acute pain re-

lated to incre-

asing of pres-

sure in middle

ear secondary to

infection process

1. Noting client’s age/

developmental level

and current condition

(e.g., infant/ child,

critically ill)

2. Noting possible pa-

thophysiological/ psy-

chological causes of

pain (e.g., inflame-

mation, trauma,

infection process)

3. Observing nonverbal

cues (e.g., how client

walks, holds body,

guarding behaviors,

grimacing facial,

narrowed focus;

crying, lethargy in

infant)

4. Monitor vital signs

during episodes of

pain

5. Administering anal-

gesic to maximal

dosage as “accep-

table” level of pain

and inform client or

1. Client at age of 2.5

years old

2. From physical

examination revealed

tympanic membrane

red and bulging

bilaterally. Client

diagnosed bilateral

otitis media by

pediatrician

3. Client seems irritable,

pulling at ears, and

crying.

4. RR: 35x/minute, pulse

100x/minute,

temperature 1020F

5. Client is given para-

cetamol 250 mg t.d.s

and amoxicillin 250 mg

t.d.s for 10 days.

Page 24: Pediatric Nursing Care (Case Study)

24

caregiver about the

medication procedure

and antibiotics to cure

the infection

6. Teaching caregiver to

note the cues of pain

and to manage

comfort for client

7. Teaching client or

caregiver to helps

client demonstrate

way to maintain same

pressure in ear (e.g.,

promote swallowing

or yawning)

6. Client’s parents can

mention some kind of

cues of pain and the

way to manage comfort

for client to reduce pain

7. Client’s parents under-

stand and know how to

helps their child to

demonstrate the way to

maintain same

pressure in ear.

3. Hyperthermia re-

lated to Increae

metabolism

secondary to

disease/infection

process

1. Noting chronological

and developmental

age of client

2. Monitoring core tem-

perature by appropri-

ate route

3. Teaching parents how

to measure child’s

temperature, at what

body temperature to

give antipyretic medi-

cations, and what

symptoms to report to

physician

1. Client at age of 2.5

years old. His mother

said that he has been

feverish since last night

2. Temperature 1020F

3. Client’s parents can

demonstrate how to

measure child’s

temperature and know

when the temperature

need antipyretic medi-

cation and what

symptoms need to be

Page 25: Pediatric Nursing Care (Case Study)

25

4. Discussing importance

of adequate fluid

intake at all times and

ways to improve

hydration status when

ill or when under

stress (e.g., exercise,

hot environment).

5. Informing families/

caregivers (of young

children, persons who

are outdoors in very

hot climate) in dangers

of heat exhaustion and

heat-stroke and ways

to manage hot envi-

ronments. Instructing

parents to avoid

leaving young children

in unattended car

6. Teaching client or

caregiver to promote

cooling by means of:

a. Limiting

clothing/dress in

lightweight, loose-

fitting clothes.

b. Cooling the envi-

ronment with air

conditioning or fans

c. Providing cool/tepid

reported to physician

4. Client’s parents ex-

press the understand-

ding of importance of

adequate fluid intake

5. Client’s parents said

that they understand of

the information that has

given

6. Client’s parents

express understanding

and knowledge in

promoting cooling for

their child

Page 26: Pediatric Nursing Care (Case Study)

26

sponge baths or

immersion if tempe-

rature is >1040F or

local ice packs,

especially in groin

and axillae (areas of

high blood flow)

4. Altered nutrition:

Risk for less

than body re-

quirement relat-

ed to decreased

appetite and the

increased meta-

bolism second-

dary to disease

process

1. Assessing client/care-

giver knowledge of

nutritional needs and

ways client is meeting

these needs.

2. Teaching client/care-

giver ways to increase

appetite:

a. Determining when

client prefers/ tole-

rates largest meal

of the day. Maintain

flexibility in timing

of food intake

b. Providing nume-

rous small feed-

ings, as indicated;

supplements with

easily digested

snack

c. Encouraging varie-

ty in food choice,

1. Client’s parents said

that they really concern

about their child

nutrition and know that

their child need

adequate nutri-tion for

his growth and

development

2. Client’s parents said

that they understand

and will try to do some

ways to increase their

child’s appetite

Page 27: Pediatric Nursing Care (Case Study)

27

varying textures

and taste sense-

tions (e.g., sweet,

salty, fresh, me-

thods of cooking)

3. Suggest client/care-

giver to increase spe-

cific nutrients (e.g.,

protein, carbohydrates,

fats and calories), as

needed, providing

client with preferred

food and seasoning

choices where

possible

4. Suggest client/care-

giver to promote

adequate/ timely fluid

intake

3. Client’s parents

verbalizing their

understanding and

willingness to provide

more specific nutrients

for their child.

4. Client’s verbalizing

their willingness to

promote adequate/

timely fluid intake for

their child

5. Family coping;

risk for growth

related to sib-

ling complex;

the new arrival

in family

1. Discussing family

perceptions of

situation

2. Identify current

behaviors of the family

members (e.g.,

ignoring/ caring client

at home; anger and

ways of touching

1. Client’s family said that

they really concern of

client growth and that

this situation can affect

in client growth

2. Client’s mother said

that indeed, after the

new born, she spent

more time to take care

of the new baby than to

client. But his husband

Page 28: Pediatric Nursing Care (Case Study)

28

between family

members, care

expressions)

3. Suggest family to

involve client in taking

care of the new baby

4. Suggest family to give

the same attention and

care to both client and

the new baby

5. Explain family about

toddler growth

6. Explain family/ parents

about the importance

of developing good

communication

between parents and

child

has been extra

attentive to client

3. Client’s family said that

they will involve client

in taking care of the

new baby

4. Client’s family said that

they will give the same

attention and care to

both client and the new

baby especially for

client’s mother

5. Family understand

about toddler growth

6. Family understand and

will develop good

communication with

their child

E. EVALUATION

Nursing Diagnosi

sEvaluation

1 S:

- Client’s parents said that they understand and will

follow the suggestion

- Client’s parents said that they understand and will

maintain their child to follow the therapeutic procedure

Page 29: Pediatric Nursing Care (Case Study)

29

as it scheduled

O:

- Respiration rate 35x/minute

- Difficulty in respiration because of nasal congestion

with clear discharge

- Client has runny nose

- Client cannot expel the secretion by coughing it up

A: Goal met partially

P: Continuing intervention and Modification to plan of care

2 S:

- Client’s parents said that they understand and know

how to helps their child to demonstrate the way to

maintain same pressure in ear

O:

- Tympanic membrane red and bulging bilaterally

- Client seems irritable, pulling at ears and crying

- RR: 35x/minute, pulse 100x/minute, temperature 1020F

- Client’s parents can mention some kind of cues of pain

and the way to manage comfort for client to reduce

pain

A: Goal met partially

P: continuing intervention and modification to plan care

3 S:

- Client’s parents understand and know how to helps

their child to demonstrate the way to maintain same

pressure in ear

O:

- Client’s parents can demonstrate how to measure

child’s temperature and know when the temperature

need antipyretic medication and what symptoms need

to be reported to physician

Page 30: Pediatric Nursing Care (Case Study)

30

- Client’s parents express understanding and knowledge

in promoting cooling for their child

- Client seems irritable, pulling at ears and crying

- RR: 35x/minute, pulse 100x/minute, temperature 1020F

A: Goal met partially

P: Continuing intervention and modification to plan care

4 S:

- Client’s parents said that they understand and will try

to do some ways to increase their child’s appetite

- Client’s parents verbalizing their understanding and

willingness to provide more specific nutrients for their

child.

- Client’s verbalizing their willingness to promote

adequate/ timely fluid intake for their child

O:

- Client/ caregiver verbalizing understanding how to

keep adequate nutrition intake

A : Goal met partially

P : Continuing intervention for client homecare and

modification to plan care

5

S :

- Client’s family said that they will involve client in taking

care of the new baby

- Client’s family said that they will give the same

attention and care to both client and the new baby

especially for client’s mother

- Family understand about toddler growth

- Family understand and will develop good com-

munication with their child

Page 31: Pediatric Nursing Care (Case Study)

31

O :

- Family can verbalize the way to cope and their willing

to cope the situation

- Family/parents verbalizing their understanding of their

child growth

A : Goal meet

P : Intervention stopped