Care Plan Peds

Student: Diana Sevilla
Patient Initials: Age: 7 M
Admitting Diagnosis Asthma Rationales Evaluation: Were the goals met? Evaluate each Short Term goal: Goal Met, oxygenation saturation 95%
Nanda Dx and Statement: Nursing Dx Impaired gas exchange r/t altered oxygen supply, retained secretions AEB: Subjective Mother says, he is not coughing out the mucus and the rescue inhaler was not helping him anymore Objective Dyspnea Labored respirations Elevated shoulders.
Goals: Short Term/Long Term One Short term: Child will have adequate airway exchange within second of admission to ER.
Nursing Interventions
3 Therapeutic 1. Maintain oxygen administration device as ordered. (C)
Attempting to maintain oxygen saturation at greater than 90% (Gulanick Nursing Care Plans 7th edition, evolve web page) Cool, pale skin may be secondary to a compensatory vasoconstrictive response to hypoxemia. As oxygenation and perfusion become impaired, peripheral tissues become cyanotic. (Gulanick Nursing Care Plans 7th edition evolve web page) Useful tool to detect changes in oxygenation. Oxygen saturation should be maintain at 90% or greater. (Gulanick Nursing Care Plans 7th edition evolve web page)
2. Assess skin, nail beds and mucous membranes for pallor or cyanosis. (I)
3. Use pulse oximetry to monitor oxygen saturation (I)
One Long Term 3 Educational Goal 1. Educate child and Goals family regarding proper Child will demonstrate use of rescue improve blood gases, medications in case of within the patients disease exacerbation.(i) normal range, within 2 days.
To prevent illness exacerbations and hospitalization; to prevent side effects from improper use of certain asthma drug. (Hockenberry, Wongs essential of Pediatric Nursing 8th edition pg. 793) To control symptoms and minimize shortness of breath. (Hockenberry, Wongs essential of Pediatric Nursing 8th edition pg. 793) Reinforces need for realistic plan of follow up and anticipatory guidance. (Newfield, Cox Clinical applications of Nursing Diagnosis 5th edition pg 348)
Evaluate each Long Term goal: Goal met and on going assessment of blood gases.
2. Educate child and family in the use of inhaled corticosteroids and bronchodilator.(I)
3. Educate child and family regarding follow up care and protection from triggering events, including exposure to respiratory infections. (I) 3 Diagnostic 1. Assess respirations noting quality, rate, rhythm, depth and breathing effort (I)
Both rapid, shallow breathing patterns and hypoventilation affect gas exchange. (Gulanick Nursing Care Plans 7th edition evolve web page)
2. Assess lung sounds (I)
Changes in lung sounds may reveal the etiology of impaired gas exchange. (Gulanick Nursing Care Plans 7th edition evolve web page) Pco2, Po2 and O2 saturation are indicators of the efficiency of gas exchange. (Newfield, Cox Clinical applications of Nursing Diagnosis 5th edition pg 348
3. Collaborate with health care team regarding monitoring ABGs (C)
Student:
Patient Initials: Age: m/ f Nursing Interventions
Admitting Diagnosis
Nanda Dx and Statement: One Educational
Goals: Short Term/Long Term
Rationales There should be 1 rationale per intervention and a reference. Include Author, Name of Book, Year, and pg. # for each rationale
One Short term (This includes the NANDA dx with Goals must be: the r/t and the 4 Measurable AEB (this should 5 Observable be broken down 6 Timed into subjective and 7 Realistic objective data) 8 Specific
3 Therapeutic (label each interventions as independent, dependent, or interdependent/collaborative)
Evaluation: Were the goals met? Evaluate each Short Term goal: This looks at the goals.
One Long Term Goal Goals must be: 1. Measurable 2. Observable 3. Timed 4. Realistic 5. Specific
3 Educational (label each interventions as independent, dependent, or interdependent/collaborative)
There should be 1 rationale per intervention and a reference. Include Author, Name of Book, Year, and pg. # for each rationale
Evaluate each Long Term goal: This looks at the goals.
3 Diagnostic (label each interventions as independent, dependent, or interdependent/collaborative)
Student:
Patient Initials: Age: m/ f Nursing Interventions
There should be 1 rationale per intervention and a reference. Include Author, Name of Book, Year, and pg. # for each rationale Admitting Diagnosis
Nanda Dx and Statement: One Psychosocial
Rationales There should be 1 rationale per intervention and a reference. Include Author, Name of Book, Year, and pg. # for each rationale
One Short term (This includes the NANDA dx with Goals must be: the r/t and the 9 Measurable AEB (this should 10 Observable be broken down 11 Timed into subjective and 12 Realistic objective data) 13 Specific
3 Therapeutic (label each interventions as independent, dependent, or interdependent/collaborative)
Evaluation: Were the goals met? Evaluate each Short Term goal: This looks at the goals.
One Long Term Goal Goals must be: 6. Measurable 7. Observable 8. Timed 9. Realistic 10. Specific
Student:
There should be 1 rationale per intervention and a reference. Include Author, Name of Book, Year, and pg. # for each rationale 3 Diagnostic There should be 1 (label each interventions as rationale per independent, dependent, or intervention and interdependent/collaborative) a reference. Include Author, Name of Book, Year, and pg. # for each rationale Patient Initials: Admitting Diagnosis Age: m/ f Nursing Interventions (label each interventions as independent, dependent, or interdependent/collaborative) 3 Therapeutic Rationales
3 Educational (label each interventions as independent, dependent, or interdependent/collaborative)
Nanda Dx and Statement:
Evaluation: Were the goals met?
One Short term
Evaluate each Short Term goal: This looks at the goals.
One Long Term Goal
3 Educational
3 Diagnostic

Care Plan Peds

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Care Plan Peds

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Student: Diana Sevilla

Patient Initials: Age: 7 M

3 Therapeutic 1. Maintain oxygen administration device as ordered. (C)

3. Use pulse oximetry to monitor oxygen saturation (I)

2. Assess lung sounds (I)

3. Collaborate with health care team regarding monitoring ABGs (C)

Patient Initials: Age: m/ f Nursing Interventions

Nanda Dx and Statement: One Educational

Goals: Short Term/Long Term

3 Therapeutic (label each interventions as independent, dependent, or interdependent/collaborative)

3 Educational (label each interventions as independent, dependent, or interdependent/collaborative)

Evaluate each Long Term goal: This looks at the goals.

3 Diagnostic (label each interventions as independent, dependent, or interdependent/collaborative)

Patient Initials: Age: m/ f Nursing Interventions

Nanda Dx and Statement: One Psychosocial

Goals: Short Term/Long Term

3 Therapeutic (label each interventions as independent, dependent, or interdependent/collaborative)

3 Educational (label each interventions as independent, dependent, or interdependent/collaborative)

Evaluate each Long Term goal: This looks at the goals.

Nanda Dx and Statement:

Goals: Short Term/Long Term

Evaluation: Were the goals met?

One Short term

Evaluate each Short Term goal: This looks at the goals.

One Long Term Goal

Evaluate each Long Term goal: This looks at the goals.

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