Javier, Jomar A.
BSN121 Group 83
Nursing Care Plan
(Pediatric Patient)
Nursing Diagnosis/ Analysis Goal and Objectives Intervention Rationale Evaluation
Cues
Diarrhea r/t infectious Scientific: Goal: Independent: After 4 days of nursing
process secondary to Passage of loose, After 4 days of nursing Restrict solid food To allow for bowel interventions, the
Acute Gastroenteritis unformed stools interventions, the intake, as rest/reduced intestinal patient reestablished
pathogens cause patient will reestablish indicated workload and maintained normal
Subjective: tissue damage and and maintain normal pattern of bowel
The mother stated inflammation by pattern of bowel To avoid foods/ functioning.
“simula palang releasing endotoxins functioning. Provide for substances that
nung na admit that stimulate the changes in dietary precipitate diarrhea After 1 hour of
kami dito nung mucosal lining of the Objectives: intake discussion, the
lunes eh nagtatae intestine resulting in After 1 hour of parent verbalized
na talaga siya” the greater secretion discussion, the Limit caffeine and It stimulates gastric understanding
She also added: of water and parent will high fiber foods; motility causative factor
“naawa na nga electrolytes into the verbalize avoid milk and and rationale for
ako sa kanya kasi intestinal lumen. The understanding fruits, as treatment
maya’t maya ay active secretions of causative factor appropriate regimen.
nagpapalit kami ng chloride and and rationale for After 1 hour of
diaper, baka nga bicarbonate ions are treatment Indicating hydration discussion, the
magka-irritation the small bowel leads regimen. Assess for parent
siya sap wet dahil to the inhibition of After 1 hour of presence of demonstrated
dun” sodium re-absorption. discussion, the postural appropriate
“Umiiyak siya To balance the excess parent will hypotension, behavior to assist
minsan at sodium, large amounts demonstrate tachycardia, skin with resolution of
nagcocomplain of protein rich foods appropriate hydration/turgor, causative factors
siya na masakit fluids are secreted in behavior to assist condition of (e.g., proper food
tiyan niya” the bowel’s ability to with resolution of mucous preparation, or
Objective: reabsorb the fluid and causative factors membranes avoidance of
Changed diaper 3x leading to diarrhea. (e.g., proper food To determine amount irritating foods)
with loose and preparation, or Weigh infant’s of output and fluid
deformed stools Situational: avoidance of diapers replacement needs
Abdominal As for the patient, the irritating foods)
distention noted causative factor of her
diarrhea is her disease
upon palpation (Acute Gastroenteritis) Encourage oral
Upon intake of fluids
auscultation, containing
hyperactive bowel electrolytes, such
sounds noted. as juices, bouillon,
Irritated and or commercial
crying. preparation as
appropriate.
Assist, as needed,
with pericare after
each bowel Because skin
movement. breakdown can occur
Provide prompt quickly when diarrhea
diaper change and is present.
gentle cleansing
Apply
lotion/ointment or
petroleum jelly as
skin barrier, as
needed.
Provide dry linen,
as necessary. To keep the area dry
Expose perineum/ because moisture can
buttocks to air; adhere skin
use heat lamp breakdown
with caustion, if
needed.
To promote return to
normal bowel
functioning
Increase oral fluid
intake and return
to normal diet, as
tolerated.
Encourage
nonirritating
liquids. Diarrhea maybe result
Discuss possible of aggravated by
change in infant intolerance to specific
formula. formula.
To restore normal
Recommend flora
products such as
natural fiber, plain
natural yogurt,
Lactinex.
Promote wellness
Review causative
factors and To prevent diarrhea
appropriate from recurring
interventions.
Evaluate/identify
individual stress
factors and coping
behavior.
Review food
preparation,
emphasizing To prevent bacterial
adequate cooking growth/
time and proper contamination
refrigeration/stora
ge.
Emphasize the
importance of To prevent spread
hand washing. infectious causes of
diarrhea such as C.
Dependent: defficile or S. aureus
Assist in
treatment of
underlying Therapies can include
conditions (e.g., treatment of fever,
infections, pain, and infectious
malabsorption toxic agents,
syndrome, and rehydration, and oral
cancer) and feeding, etc.
complications of
diarrhea.
Review laboratory
studies for
abnormalities.
Administer enteral
and IV fluids as
indicated.
Administer anti- To decrease
diarrheal gastrointestinal
medications, as motility and minimize
indicated fluid losses.
Administer To treat infectious
medications, as process, decrease
ordered. motility, and/or absorb
water.
Nursing Diagnosis/ Analysis Goal and Objectives Intervention Rationale Evaluation
Cues
Impaired oral mucous Goal: Independent:
membrane r/t trauma After 5 days of Routinely inspect
nursing interventions, oral cavity and
Subjective: the patient will show throat for
The mother state: a decrease in signs inflammation,
“Me singaw siya sa
and symptoms as sores, lesions,
bibig, minsan
umiiyak siya pag noted in defining and/or bleeding.
pinpapakain ko siya characteristics. Determine if
at minsan dinudura patient is
niya at umiiyak” Objectives: experiencing pain
Objective: After 2 hours of or painful
Single ulceration on discussion, the swallowing.
the mucosal wall parent will Encourage To prevent dry mouth
noted. verbalize adequate fluids. and dehydration.
understanding of
causative factors.
After 2 hours of Provide dietary To reduce discomfort/
discussion, the parent modifications improve intake and
will demonstrate (e.g., food of promote healing
techniques to comfortable
texture,
restore/maintain
temperature,
integrity of oral density) and
mucosa. adequate nutrients
and vitamins.
Avoid irritating
foods/fluids,
temperature
extremes; provide
soft or pureed diet
as required.
Assist/ provide
oral care, as
indicated.
Review current To correct
oral hygiene deficiencies and
patterns and encourage proper
provide care.
information about
oral health as
required/desired.
Instruct parents in
oral hygiene Encourage early
techniques and initiation of good oral
proper dental care health practice and
for timely intervention
infants/children for treatable
(e.g., use of problems.
pacifier, brushing
of teeth and
gums, avoidance
of teeth and
gums, avoidance
of sweet drinks
and candy,
recognition and
treatment of
thrush.)
Promote general/ Altered immune
mental health. response can affect
the oral mucosa.
Provide nutrional
information. To correct
deficiencies, reduce
irritation/ gum
disease, prevent
dental carries.
Stress importance
of limiting night
time regimen of To prevent bottle
bottle of milk for syndrome with
infant in bed. decaying of teeth.
Suggest pacifier
or use of water
during night.
Dependent:
Administer
antibiotics, as When infection is
ordered present
Review
information
regarding drug
regimen , use of
local anesthetics.
