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Nursing Care Plan

Patients Name: Muhammad Azan.

Age: 5 years M.

Father Name: Muhammad Shafiq. Ward: Paeds.

Date: 05/12/2014

Assessment Diagnosis
Subjective Data:
1. Yellowish
discoloration
of eyes and
Mucous
membrane.
2. Ears are
checked with
pen torch for
any secretion
but no such
condition is
noted.
3. Patients
stands still
then I
measured its
height with
measuring
tape. Patients
height is 2.10
feet.
4. With the help
of pen torch I
checked the
nose patency
Anil

Planning
Short Term
Planning:

Jaundice related
to disease
process as
evidence by
yellowish
discoloration of
eyes/protruded
abdominal
cavity.

Intervention Rationale

(i).Allay
Restlessness.

Evaluate adequacy
These assessments
of nutrition and sleep have all been shown
patterns.
to have good internal
reliability.

(ii). Patient will


exhibit no signs of
cold stress.

Maintained Quiet
environment.

For quick recovery.

Maintained
adequate fluid
intake.

To prevent from
dehydration.

(iii). At regular
intervals assess
patients eyes,
mucous membrane,
skin integrity. Also
perform physical
assessment of liver.
To note any
complication.

Monitor intake and


output.

Regular changing in
position.

Evaluation
Checked
satisfactory level of
Patients attendant
and patient itself.

Having no adequate
fluid intake will
lead to further
complications such
as hypovolemia and
hypokalemia.

To prevent from
bed sore.

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for any lesion


and blockage.
Nose is patent
and no lesion
is seen.
5. Vitals
checked:
Pulse: 90 bpm
Temp: 98.7 F
Resp.: 38/min
6.
Skin is assessed.
Patients skin is dry.
Partial hair
distribution. Wounded
scars are seen.
Lesions are present.

Objective Data:
1. Patients
mother told
that he has
pain in his
stomach for 6
days.
2. Day by day
he is
becoming
weak.
3. They told me
that after this they
brought him to
hospital.
Anil

Long term
Planning:
1. Teach clients
relatives about the
disease so that they
properly take care
of patient at home.
If doctors
discharge him.
2. Medications:
Paeds solution.
Heptocam syp.
Glare syp.
Glucose D,
Amoxil
125mg/5ml.Syp.

Drink boiled water.


We already know
that water of our
country is not of
good quality.
Therefore to prevent
from other
infections and water
borne diseases
patient must drink
boiled water.

Review Knowledge
of the clients
family.

This will help them


to take further care
of their patient.

Kept skin clean and


moist.

This helped me to
note further
deviations from
normal.

Told the client and


its family members
to avoid and limit
eatable things from
outside such as
snacks, chips and
other oil cooked
products.

The response of
patient and its
family members
towards seeking
health care was
positive and they
are cooperative.

I gave informal
education to patient
to aware them about
the disease. Then I
asked them
questions and they
answered few of
them. This ensures
some
understanding.

The oil used in


these things is of
low quality and
these eatables are
cooked again &
again in same oil to
which person is
more vulnerable to
diseases not only
jaundice but may
also leads to cancer
etc.

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Anil

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