Nursing Care Plan

Nursing Care Plan
In Partial Fulfilment of the

Requirements in NCM 209 – RLE
PEDIATRIC ROTATION
Submitted to:
Mrs. Ariane Mae P. Soriano, RN
Clinical Instructor
Submitted by:
Cyruz Val G. Martillano
BSN 2E - Group 3
April 25, 2019

Date Cues Need Nsg. Dx Patient Planning of Implementatio Evaluation
& Outcome Intervention n
Time
A Subjective Cues: C Disturbed After 7 hours of 1. Identify client April 20, 2020
P “Ma, akong mata, O sensory nursing with condition 1 @ 2:30
R dili kaayo ko G perception interventions, that can affect “GOAL MET”
I makaklaro og tan- N (visual) the patient will sensing, After 7 hours of
L aw” as verbalized I related to be able to: communicatin nursing
by the patient” T glucose g stimuli. intervention, the
2 I imbalance a. Report Rationale: patient was
0 Objective Cues: V Rationale: correction Specific clinical able to;
 vomiting E High levels of blurred concerns (e.g. a. Verbalize
2  nausea / of blood vision biochemical “oo
0  restlessness P sugar b. Keep the imbalances) have kaklaro
2 E resulting blood the potential for nako og

 blurred
0 R from glucose altering one or tan-aw
vision
@7:3 C diabetes levels in more of the te”
 extreme
0 AM thirst E can affect normal senses. b. Maintain
 urinate more P the ability range 2. Obtain blood the blood
often than T to see by glucose level. 2 glucose
usual U causing Rationale: To in normal
A the lens determine most range
L inside the appropriate
eye to dosage of insulin.
P swell, 3. Test blood
A which can glucose. 3
T result in Rationale: To
T temporary evaluate glucose
E blurring of level
R eyesight. 4. Review results
N of sensory and 4
laboratory
studies (e.g.
laboratory
values such as
electrolyte,
serum drug
levels)
Rationale: To note
presence or possible
cause of changes in
response to sensory
stimuli.
5. Administer
insulin as
prescribed 5
Rationale: To
maintain normal
blood glucose level.
6. Evaluate
visual acuity,
as indicated 6
Rationale: Retinal
edema or
detachment
temporary paralysis
of extraocular
muscles may impair
vision, requiring
corrective therapy or
supportive care.
Retinopathy is a very
common
microvascular
complication
associated with
diabetes.
7. Encourage the
parents to take
the child to the 7
eye doctor
regularly
Rationale: So any
problems can be
detected and treated
early.
8. Educate about
home glucose
monitoring
Rationale: to identify 8
and manage glucose
variations.
9. Encourage the
parents to
make a meal
plan that fits to
their child's
food 9
preference
Rationale: Food is a
big component of any
diabetes treatment
plan, it also helps in
keeping the blood
sugar level as close
to normal.
10. Encourage
the kid to do
exercise
Rationale: Better
response to insulin
and better blood

sugar control 10
References:
Doenges, M. E., Murr, A. C., & Moorhouse, M. F. (2014). Nurse's pocket guide: Diagnoses, prioritized interventions, and
rationales. Philadelphia Pennsylvania: F.A. Davis Company.
Ward, K., Wong, D. L., & Hockenberry, M. J. (2012). Study guide for Wong's essentials of pediatric nursing, ninth edition.
St. Louis, Mo: Mosby.
Watts, M. (2019, January 15). Blurred Vision. Retrieved from https://www.diabetes.co.uk/symptoms/blurred-vision.html

Date Cues Nee Nsg. Dx Patient Outcome Planning of Implementatio Evaluation
& d Intervention n
Time
A Subjective Cues: N Deficient fluid After 7 hours of 1.Obtain April 20,
P “Ma, tubig, giuhaw U volume nursing history from 1 2020
R nasad kaayo ko” T related to interventions, the the patient or @ 2:30
I as verbalized by R osmotic patient will be able parent related “GOAL
L the patient. I diuresis as to: to duration MET”
T evidenced by a. Demonstrate and intensity
2 Objective Cues: I increase adequate of symptoms
0  Weakness O urine hydration as such as
 Extreme N concentratio evidence by excessive
2 thirst A n electrolyte levels urination
0  Sudden L Rationale: within the normal Rationale:
2 weight loss In DKA, there range Helps
0  Poor skin M is an excess estimate total
@7:30 turgor E of glucose, in volume
AM  Dry skin T an attempt to depletion.
A rid it, kidneys Symptoms

 Increase
B excrete may have
pulse rate
O glucose been present
 Excessive
L along with for varying
urination
I water and amounts of
References:
Moorehouse, M., Doenges, M., & Murr, A. (2014). Nursing Care Plans: Guidelines for Individualizing Client Care Across
the Life Span,9th Edition. FA Davis Company.
Hinkle, J. L., Cheever, K. H., & Hinkle, J. L. (2018). Brunner & Suddarth's textbook of medical-surgical nursing.
Philadelphia: Wolters Kluwer.

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Nursing Care Plan

In Partial Fulfilment of the

April 25, 2019

& Outcome Intervention n

P “Ma, akong mata, O sensory nursing with condition 1 @ 2:30

R dili kaayo ko G perception interventions, that can affect “GOAL MET”

I makaklaro og tan- N (visual) the patient will sensing, After 7 hours of

L aw” as verbalized I related to be able to: communicatin nursing

by the patient” T glucose g stimuli. intervention, the

2 I imbalance a. Report Rationale: patient was

0 Objective Cues: V Rationale: correction Specific clinical able to;

 vomiting E High levels of blurred concerns (e.g. a. Verbalize

2  nausea / of blood vision biochemical “oo

0  restlessness P sugar b. Keep the imbalances) have kaklaro

2 E resulting blood the potential for nako og

 urinate more P the ability range 2. Obtain blood the blood

often than T to see by glucose level. 2 glucose

usual U causing Rationale: To in normal

A the lens determine most range

L inside the appropriate

eye to dosage of insulin.

P swell, 3. Test blood

A which can glucose. 3

T temporary evaluate glucose

R eyesight. 4. Review results

blood glucose level.

muscles may impair

the child to the 7

detected and treated

and manage glucose

big component of any

plan, it also helps in

keeping the blood

sugar level as close

and better blood

rationales. Philadelphia Pennsylvania: F.A. Davis Company.

St. Louis, Mo: Mosby.

Watts, M. (2019, January 15). Blurred Vision. Retrieved from https://www.diabetes.co.uk/symptoms/blurred-vision.html

P “Ma, tubig, giuhaw U volume nursing history from 1 2020

R nasad kaayo ko” T related to interventions, the the patient or @ 2:30

I as verbalized by R osmotic patient will be able parent related “GOAL

L the patient. I diuresis as to: to duration MET”

T evidenced by a. Demonstrate and intensity

2 Objective Cues: I increase adequate of symptoms

0  Weakness O urine hydration as such as

 Extreme N concentratio evidence by excessive

2 thirst A n electrolyte levels urination

0  Sudden L Rationale: within the normal Rationale:

2 weight loss In DKA, there range Helps

0  Poor skin M is an excess estimate total

@7:30 turgor E of glucose, in volume

AM  Dry skin T an attempt to depletion.

A rid it, kidneys Symptoms

the Life Span,9th Edition. FA Davis Company.

Philadelphia: Wolters Kluwer.

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