pediatric nursing care (case study)
DESCRIPTION
a case study in patient with otitis media and upper respiratory infectionTRANSCRIPT
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
2
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
3
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
4
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.
5
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
6
- 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
7
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
8
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
9
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
10
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
11
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
12
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
13
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
14
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
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
16
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
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-
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
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
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
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
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
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.
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
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
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
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
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
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
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
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