NURSING MANAGEMENT:

Assessment

The nurse collects a detailed history and conducts a through physical examination to reveal the following problems the client faces:

 Difficulty in breathing.
 Cough.
 Elevated body temperature.
 Less intake of food.
 Anxiety among the parents.
 Increased perspiration
 Frequent questioning by parents about care of child.

Based on the above problems the diagnosis is set according to the priorities

Actual Nursing Diagnosis

1) Ineffective breathing pattern related to inflammatory process characterized by dyspnea, tachypenia, productive cough, shallow
respirations.
2) Impaired gas exchange related to altered oxygen supply.
3) Hyperthermia related to lower respiratory tract infections manifested by abrupt onset of high body temperature, tachycardia,
tachypnea, warm to touch.
4) Altered nutrition; less than body requirements related to inability to ingest food or digest food because of biological factors
manifested by lack of interest in food, anorexia, cough.
5) Anxiety of the parents and child related to threat to or change in the health status of child manifested by apprehension that
condition of child may worsen.
6) Knowledge deficit of parents related to unfamiliarity with disease and complications characterized by verbalization of need for
information about medication, activity and rest.
Potential diagnosis:

1) High risk for fluid deficit related to excessive losses through normal routes and less intake of fluids, increased body
temperature; dehydration.
2) High risk for injury related to internal factors of pulmonary complications in the child evidenced by fluid accumulation in the
pleural cavity, dyspnea, pneumothorax.
 NURSING CARE PLAN

NURSING NSG. GOALS PLANNING IMPLEMENTATION RATIONALE EVALUATION

ASSESSMENT DIAGNOSIS

Subjective data: Ineffective Short-term: -Provide position with -Child was positioned -Facilitates chest Short-term:
“ My child have breathing After 4 hours head elevated or seated with head elevated and expansion and After 15 mins. Of
very difficulty in pattern related of upright with head on seated upright with head respiratory intervention, the
taking breaths” as to intervention, pillows; position on side on pillow. efficiency by patient
verbalized by inflammatory patient will if more comfortable. reducing the manifested
mother process have adequate pressure of absence of
characterized oxygenation. abdominal organs or dyspnea with RR
by dyspnea, diaphragm. of 50-60 cpm
Objective data: tachypenia, with minimal
 tachypnea productive -Improve the ventilation -I have opened the -Fresh air replaces wheezing,
 ineffective cough, in room. windows of room for co2 and make the crackles, and
cough shallow Long-term: proper ventilation of the ward more irritability.
noted respirations. room. concentrated with o2.
 crackles After 16hours Long-term:
and of -Administer oxygen if -Oxygen inhalation was -To provide direct
wheezing intervention, required. started to improve supply of oxygen to
After 16hours of
noted upon Patient will breathing and to prevent lungs for easy intervention,
auscultatio establish a hypoxia. breathing. Patient
n normal/effecti established a
 irritability ve respiratory -Administer -Bronchodilator; inj. -Relieves normal/effective
 rapid pattern as bronchodilators as Deriphyllin has been bronchospasm that respiratory
shallow evidenced by prescribed by the administered by i/v route. affect respirations pattern as
breathing RR of 50-60 physician. (tachypnea). evidenced by RR
 cyanosis cpm and of 50-60 cpm and
absence of -Try out the -Chest physiotherapy; -Helps in drainage of absence of
wheezing, physiotherapy measures. chest percussion was secretions. wheezing,
crackles, performed. crackles, dyspnea,
 dyspnea, and and irritability
irritability.
Subjective data: Impaired gas Short term: -Monitor respiratory rate -Respiratory rate, depth -Manifestations of Short term:
“My daughter’s exchange After 4 hours is monitored. respiratory distress After 4 hours of
skin is becoming related to of are dependent intervention, the
pale, she is having altered intervention, on/and indicative of family verbalized
difficulty in taking oxygen the family the degree of lung understanding of
breaths” supply will verbalize involvement and causative factors
as verbalized by understanding underlying general such as inhaled
mother. of causative health status. bacteria and
factors and appropriate
appropriate -Assess the color of -Color of skin, mucous -To note respiratory interventions such
Objective data: intervention skin, mucous membranes and nail beds compromise as medication
 Irritability membranes and nail is observed, peripheral compliance and
(+) beds. cyanosis was present. adequate
 Abnormal breastfeeding
Skin Color: -Provide comfortable -Head end of bed/ -To maintain airway
Pale & position. position client is and enhance gas
Dusky elevated. exchange Long term
 Tachypnea After 1 week of
w/ RR= -Change the position -Patient’s position is -To mobilize intervention, the
74cpm Long Term: every 2 hourly. changed at least every 2 secretions and allow patient
 Tachycardi After 1 week hours serration of all lung demonstrated
a HR= 168 of fields improved
intervention, ventilation and
the patient -Feed the child as per -Mother is instructed to -This mobilizes adequate
will baby’s demand. feed the baby per secretions. I & O is oxygenation of
demonstrate demand. Intake and essential to monitor tissues as
improved output is recorded. fluid status manifested by
ventilation absence of
and adequate -Encourage the calm and -Rest is encouraged. Helps limit Oxygen irritability,
oxygenation comfortable Calm/restful environment consumption. pinkish skin
of tissues environment. has been promoted. color.
 manifested by RR bet
absence of -Assess the vital signs. -Vital signs and cardiac -Tachycardia may 50cpm to
symptoms of Rhythm are assessed. represent a response 60cpm
respiratory to hypoxia HR bet
distress such 168 bpm
as irritability, -Monitor the oxygen -Oxygen therapy is -Increases alveolar to 160
pale skin, therapy. monitored. 02 concentration and bpm
tachypnea and enhances arterial And
tachycardia blood oxygenation nailbeds
and
mucous
membrane
s moist
and pink.
Subjective data:Hyperthermia Short-term: -Assess the vital signs. -I have checked the Provide information Short-term:
Mother related to temperature by axilla and about temperature
complained child’s
lower After 30 noted it in TPR chart at changes caused by After 30 minutes
body is warm to respiratory minutes of frequent intervals. high susceptibility to of nursing
touch tract nursing fluctuations in intervention,
infections intervention, infants. patient’s
Objective data: manifested by patient’s temperature
 Warm skin abrupt onset temperature -Provide cold sponging -Tepid sponge bath was -Reduce temperature decreased from
 Tachypnea of high body will decrease or tepid sponge bath if given to the child, by conduction of 39.7 °C to 38.6 ºC
 Temperatur temperature, to required. previous temperature- heat from the body
e tachycardia, approximately 1010 F. After tepid to treat
tachypnea, 38.0ºC sponge bath- 990 F hyperthermia.
warm to Long-term:
touch. Long-term: -Provide additional -Additional fluids has -Maintain hydration
fluids by oral or i/v been provided by oral when fluids are lost After 8 hours of
After 8 hours routes. and i/v routes. through fever or nursing
of nursing hyperthermia. intervention,
intervention, patient
patient should -Administer antipyretics -Syrup Nimusol plus has -Antipyretic drugs maintained core
 maintain core if required. been given to the child help to relieve fever. temperature
temperature within normal
within normal range from
range: 36.8 °C 36.8ºC- 37.0 ºC
to
37.0 °C

Subjective data: Altered Short-term: -Assess the nutritional -Assessment is done by -Provide Short-term:
Mother told child nutrition; less Child will status of child. assessing height and anthropometric Child starts to
is not taking milk than body start to take weight and compare with information about take breast-milk
and other weaning requirements at-least fluid the previous values and body’s fat and and fruit juice
food items. related to diet 2-3 times standard charts. protein content and without
inability to in a day. general nutritional manifesting
Objective data: ingest food or status. nausea on the first
Child is avoiding digest food day .
food, having because of -Offer small and -Small and frequent -Easy to digest and
nausea, also biological frequent feeding with feedings has been fulfill the additional
having weight factors Long-term : increased amount of provided to the child. requirement for
loss. manifested by After 2-3 days protein. protein.
lack of child takes Long –term:
interest in food 4-5 times -Provide protein foods -Protein rich food is -Protein helps in After three days
food, in a day. in each small meal. provided during each normal growth and child starts to take
anorexia, meal. development of the normal diet.
cough. child.

-Request the family -I told the family -Favorite foods will

members to bring foods members to bring child’s be appealing for the
from home according to favorite food items from child, he will eat it
choice of child. home. with enjoyment.

Subjective data: Anxiety of the To relieve the -Ensure the parents -I have ensured the -To make sure to the Anxiety is
Parents verbalized parents and anxiety of about child’s safety in parents that their child parents that their relieved to some
that they are very child related parents by hospital even in their will not be left child will get the extent as
scared of their to threat to or providing absence. unattended in the ward. best and continuous verbalized by the
child’s condition. change in the information care in the hospital. parents on every
health status about their -Allow the parents to -Parents were allowed to -Provide opportunity day. Now they are
Objective data: of child child’s ask their doubts about express concerns and ask to ventilate feelings, participating in
On observation manifested by disease their child’s illness. questions regarding secure information child- care with
parents look apprehension condition.. condition of ill child. needed to reduce more confidence
anxious and afraid that condition anxiety. and interest.
about their child’s of child may
disease condition. worsen. -Involve parents in -Parents has been -Promotes constant
taking decisions about encouraged to remain monitoring of
their child’s care calm and involved in care child’s condition for
and decision making improvement or
regarding child’s needs worsening of
and to the improvements symptoms.
in the child’s condition.

-Allow the parents to -Parents were allowed to -Allow parents to

care their child as far as stay with child and they care for and support
possible. were assisted in care child instead of
. (hold, feed, bathe, increasing anxiety.
clothes).

Subjective data: Knowledge To improve -Provide information -Information and -Ensure Parents
“Nobody in our deficit of the and explanations in clear explanations are provided understanding based knowledge is
family has such parents knowledge of and understandable in clear, understandable on readiness and improved, they
disease, how my related to parent’s about language. language with the use of ability to learn; are able to tell
daughter gets this unfamiliarity their child’s pictures and charts in visual aids reinforceabout the
disease.” with disease disease teaching about disease. learning. causative factors
Mother verbalized and condition and of child’s disease.
by crying. complications hence helping -Educate the parents Parents are instructed in -Provide information Mother is giving
characterized them in regarding medications. administration of about drug therapy, medicine as
by providing care medications including which is the ordered at correct
Objective data: verbalization to their child action of drugs, dosages, important treatment time and she is
 of need for in a better time, frequency, side- for the cure of checking the side-
Parents ask information way. effects, expected results, pneumonia. effects every-day.
frequent questions about methods to give
about the child’s medication, medications.
disease. activity and
rest. -Help the parents to plan -Parents have been -Promotes proper
menu for their child. assisted to plan feeding, diet, which enhances
and to develop menu for health status and
appropriate inclusion of adequate fluid intake
nourishing fluids, daily which prevents
caloric requirements of dehydration.
the child.

-Tell about the need and -Instructed in care of -Prevents

importance of used tissues and to cover transmission of
preventive measures. mouth and nose when microorganisms by
coughing or blowing droplets dispersed
nose, proper hand- into the air or by
washing techniques for hands.
the parents and child.

Risk factors: High risk for Short term: -Measure the fluid -Intake is assessed and -Provides strict I&O At the end of 4
 Loss of fluid deficit At the end of intake and output of the compared with the losses to determine positive hours nursing
fluid related to 4 hours child. q2-8 h for I &O or negative balance interventions, the
through excessive nursing determinations and and potential for mother:
normal losses through intervention, balance oral intake. fluid deficit/  Verbalized
routes. normal routes the mother dehydration: understan
and less will be able Mild ding of the
 Factors intake of to: dehydration: risk
influencing fluids, -Verbalize less than 50 factors for
fluid needs increased understanding ml/kg fluid her child
as body of the risk loss  Identified
temperatur temperature; factors for her Moderate interventio
 e dehydration. child dehydration: ns that
elevation(d 50-9- ml/kg will
iaphoresis) -Identify Severe prevent or
interventions dehydration: reduce the
 Increased to prevent or about 100 risk of
insensible reduce risk of ml/kg fluid
loss(respira fluid volume volume
tions, deficiency. Try to assess fluid loss Weight is assessed on Determine losses deficiency.
perspiratio by checking weight loss same scale daily in related to fluid
n) -The patient of the child. morning. deficit and potential
will be for dehydration in
afebrile. infants
Mild
Long term: dehydration:
At the end loss of 5%
of 2 days of Moderate:
nursing loss of 10%
intervention, Severe: loss
the mother 15%
will be able
to: Assess the child for Child has assessed for Reveals signs and
-Demonstrate fluid and electrolyte fluid and electrolyte symptoms of
lifestyle depletion. depletion. electrolyte
changes to imbalance which are
promote fluid related to specific
intake of the diseases.
child.
Increase oral fluid intake Encourage increased oral Provide replacement
if child is able to retain. fluid intake in proportion of lost fluids if able
to losses – to retain by oral
150 ml/kg/day. route; child requires
750-2000 ml/day
fluids depending on
 age and weight and
calculations of
losses.

Provide pedialyte for Promotes fluid and

infant, alternate formula electrolyte
feedings with water replacement and
feedings if appropriate. prevents risk of
dehydration and
electrolyte depletion.
Risk Factors: High risk for Short term: Assess vital signs and Vital signs has been Changes revealed in At the end of 4
infection At the end of breath sounds, cough assessed every 4 hourly early stages of hours nursing
 Inadequate (spread) 4 hours and ability to cough up along with the breath complications and interventions, the
primary related to nursing secretions. sounds and ability to reveals airway mother:
defenses internal intervention, cough up the secretions. potency and dyspnea  Verbalized
particularly factors of the mother caused by fluid understan
decrease in pulmonary will be able accumulation in ding of the
ciliary complications to: pleural cavity and risk
action in the child -Verbalize secretion factors for
 Immnosup evidenced by understanding accumulation in her child
pression fluid of the risk airway.  Identified
 Presence of accumulation factors for her interventio
existing in the pleural child. Monitor temperature for Body temperature is Reveals a sudden, ns that
infection cavity, sudden rise. assessed regularly to find rapid rise in will
dyspnea, -Identify out the sudden rise. temperature which prevent or
pneumothorax interventions may trigger a febrile reduce the
. to prevent or seizure. risk of
reduce risk of infection
infection Report detection of Child is assessed for Allows for
possible respiratory respiratory immediate
-The patient complications early complications. preventative
will be (chest pain, dyspnea, measures to be taken
afebrile cyanosis, abdominal during course of
Long term: distention). disease.
At the end
of 2 days of Stress proper hand Emphasis has been given To prevent transfer
nursing hygiene on hand washing of microorganisms
intervention, techniques.
the
mother/SO Maintain a germ-free Measures has taken to To prevent spread of
will be able environment make the environment microorganisms
to: germ-free. from environment to
-demonstrate patient
techniques,
lifestyle Emphasize necessity of Parents have told about To prevent return of
changes to taking antiviral/ the importance of infection &
promote safe antibiotics, as directed antibiotics and antiviral potentiate drug-
environment (dosage & length drugs along with their resistant strains
of therapy) dosages and length of
therapy.

Administer prescribed Prescribed antibiotics To prevent further

antimicrobial/antiviral have been administered spread of
agents at scheduled time as per doctor’s orders. microorganism in
the body
HEALTH EDUCATION:

 Parents are instructed in administration of medications including action of drugs, dosages, time, frequency, side-effects,
expected results, methods to give medications.
 Parents have been assisted to plan feeding, and to develop menu for appropriate inclusion of nourishing fluids, daily caloric
requirements of the child.
 Instructed in care of used tissues and to cover mouth and nose when coughing or blowing nose, proper hand-washing
techniques for the parents and child.

CONCLUSION:

 Breathing pattern improved as after 15 mins. of intervention, the patient manifested absence of dyspnea with RR of 50-60 cpm
with minimal wheezing, crackles, and irritability.
 Patient established a normal/effective respiratory pattern as evidenced by RR of 50-60 cpm and absence of wheezing, crackles,
dyspnea, and irritability.
 Family verbalized understanding of causative factors such as inhaled bacteria and appropriate interventions such as
medication compliance and adequate breastfeeding
 Patient demonstrated improved ventilation and adequate oxygenation of tissues as manifested by absence of irritability,
pinkish skin color. Vital signs are within normal limits.
 Child starts to take breast-milk and fruit juice without manifesting nausea on the first day. After three days child starts to take
normal diet.
 Anxiety is reduced to some extent as verbalized by the parents on every day. Now they are participating in child- care with
more confidence and interest.
 Parents knowledge is improved, they are able to tell about the causative factors of child’s disease. Mother is giving medicine as
ordered at correct time and she is checking the side-effects every-day.
BIBLIOGRAPHY:

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4. Viswanathan J., Desai BS. Achar’s textbook of paediatrics. 3rd ed. Madras: Orient Longman Ltd.; 1989. P.

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