Nursing Care Plan

1. Neonate

Scenario: Newborn Preterm Birth Care Plan

Assessment Diagnosis Desired Outcomes Interventions Rationales Evaluation

Subjective Data: • Ineffective • After 30 minutes Independent: • Assessment provides • After 30 minutes of
breathing of nursing information about the nursing interventions,
N/A pattern related interventions, the • Assess RR and neonate’s ability to desired outcome is
to immature neonate will pattern initiate and sustain an partially met, the
Objective Data: neurologic and experience an • Provide effective breathing neonate experienced an
delayed effective respiratory pattern effective breathing
• Preterm Birth (33 pulmonary breathing pattern assistance as • Assistance helps the patter manifested by the
weeks and 1 day) development. as manifested by needed (Oxygen newborn by clearing - Neonate’s RR ranging
• With oxygen hood hood) the airway and between 40 and 60
regulated at 10 - Neonate’s RR is • Position neonate promoting oxygenation - Neonate experienced
liters per minute between 40 and on side with a • Lying on the side less episodes of Apnea
• RR:58 cycles per 60 rolled blanket position facilitate
minute - Neonate will no behind his back. breathing
• Episodes of apnea longer experience • Provide tactile • Stimulation of the
6-10 seconds) apnea stimulation during sympathetic nervous
• O2 saturation of periods of apnea system increases
91% respiration
 2. Infant

Scenario: Infant suffering from RSV (Respiratory Synctial Virus)

Assessment Diagnosis Desired Outcomes Interventions Rationales Evaluation

Subjective Data: • Hyperthermia • Absence of Fever Independent: • Keeping the room warm but • Monitor for the vital
• According to related to • Respiratory rate is not overheated is important, if signs of the infant
mother there is dehydration within normal • Usage of the air is dry, a cool-mist • Absence of fever
decrease in • Fluid deficit limits Humidified Air humidifier or vaporizer can must be observed
appetite related to • Patient will not • Encouraging oral moisten the air and help ease • Document any
• Cough producing decreased fluid experience fluid Intake congestion and coughing; be changes of the
yellow and green intake dyspnea at rest. • Encourage good sure to keep the humidifier infant’s cough and
mucus • Impaired gas • Patient will hygiene Habits clean to prevent the growth of appetite.
• Unusually upset or exchange related experience ease of bacteria and molds. • Document all the
inactive to possible viral breathing Collaborative: • Keep a steady supply of cool medication given
• Non-stop pneumonia • Physician will water at the bedside table;
coughing during administer offer warm fluids such as soup
the day, more at medications which may loosen thickened
night secretions; ice pops may be
soothing as well; continue
Objective Data: breast feeding or bottle
• Runny Nose, feeding your infant as you
Sneezing and would normally
Wheezing • Advice children the importance
• Positive RSV test of handwashing; using own
through glass or disposable cups when
examination someone else is sick, label the
• Vital Signs: cups.
Temp: 37.2 • Give prescribed medications
Heart Rate: 152 and encourage compliance
bpm
RR:32 bpm
 3. Toddler

Scenario: Toddler with Impaired Skin Integrity

Assessment Diagnosis Desired Interventions Rationales Evaluation

Outcomes
Subjective Data: • Risk for Impaired • Patient Independent: • Specific types of dermatitis • Document all the
N/A Skin Integrity maintains may have characteristic topical medications
Objective Data: related to optimal skin • Assess skin, noting color, patterns of skin changes and given to the client
• Inflammation contact with integrity moisture, texture, lesions • Note for any lesions
• Dry and Flaky skin irritants or within limits temperature, edema or • Flexural areal (Elbows, neck, and allergic
• Rashes, erosions allergens of the tenderness posterior knees) are common reactions to
• The toddler is disease, as • Assess the skin areas affected in atopic products introduced
experiencing pain evidenced systematically, look for dermatitis. to toddler.
and has few by intact areas for irritant and • Patients may develop • Note for
blisters skin allergic contact dermatitis in response to improvements in
• Identify aggravating changes in their environment. the toddler skin
factors, ask about Extremes temperature,
changes in use of emotional stress and fatigue
products as soaps, may contribute to dermatitis
laundry products, • One of the first steps in
cosmetics, wool or management of dermatitis is
synthetic fiber,etc. promoting healthy skin and
• Encourage the patient to healing of skin lesions.
adopt skin care routines • These drugs reduce
to decrease skin inflammation and promote
irritation heling of the skin. If these are
• Apply topical steroid not effective, the physician
creams or ointments may include prescription
corticosteroids for topical .
 4. Pre School

Scenario: Children and Pre School age with Gastroenteritis

Assessment Diagnosis Desired Interventions Rationales Evaluation

Outcomes
Subjective Data: • Risk for Diarrhea • The patient’s Independent: • If the doctor is aware of the • Monitor the
• Vomiting and related to feces culture patient’s feces pattern, he will patient’s feces
Nausea for five infections will yield • Examine the patient’s be able to prescribe pattern.
days now caused by unfavourable feces pattern appropriate treatment • Observe if the stool
• Crams and bacteria, viruses, results from • Examine the patient for immediately. of the child has
abdominal or parasites laboratory abdominal discomfort, • These assessment findings are become softer and
discomfort secondary to tests cramps, hyperactive frequently associated with bowel movement
gastroenteritis • Patient will bowel movements, diarrhea, when gastroenteritis became normal
as evidenced by release soft, recurrence, urgency, and affects the large intestine, the • Monitor the child’s
Objective Data: abdominal pain formed stool watery stool colon cannot absorb water, body temperature
and cramps, not more • Submit the stool of the resulting in excessively watery regulation
• Vital signs as more than three than three patient for the culture feces. • Document all the
follow: stools per day, times a day. • Advice the patient the • A culture is a test that findings and the
Temp: 38.3 overactive bowel • Regulation of necessity of cleaning determines which medication given.
• Feces with pus, movements, temperature their hands after every microorganisms trigger an
watery and watery stool, bowel movement and infection.
overactive bowel urgency before cooking meals for • Contaminated hands can
movement others. rapidly spread microorganisms
• After each bowel to utensils and surfaces used in
movement, educate the food preparation. Thus, hand
patient about perianal washing after each bowel
hygiene. movement is the most
• Advise the patient to effective strategy to avoid
drink 1.5 to 2.5 litres of infection transmission to
liquids per 24 hours, others.
adding 200 ml for every • The anal area should be
thoroughly cleaned to avoid
 water stool, otherwise skin irritation and
contraindicated microorganism dissemination
• Encourage patient to after a bowel movement.
consume potassium-rich • Fluid lost in liquid stools is
meals replaced by increasing fluid
intake
Collaborative: • When a patient experiences
• Advise the patient to persistent diarrhea, the
take antidiarrheal drugs potassium-rich stomach
as directed by the health contents are flushed out of the
care gastrointestinal system into
the feces and out of the body,
leading to hypokalemia.
• Adsorbent antidiarrheals are
often used to manage
gastroenteritis diarrhea. This
class of antidiarrheal
medications coats the gut
membrane and absorbs
bacterial toxins.
 5. School Age

Scenario: School Age suffering from measles

Assessment Diagnosis Desired Interventions Rationales Evaluation

Outcomes
Subjective Data: • Risk for • Within 4 Independent: • To assist in creating an accurate • Monitor the
• Runny Nose Hyperthermia hours of • Assess the patient’s diagnosis and monitor patient’s fluid
• Fever for 5 days related to nursing vital signs at least effectiveness of medical intake.
• Rashes, small ineffective interventions, every 4 hours treatment, particularly the • Monitor the child’s
spots process of the patient • Remove excessive antivirals and antipyretics body temperature
• Profuse sweating rubeola as will have a clothing, blankets, administered and pulse
evidenced by stabilized and linens. Adjust the • To regulate the temperature of the regulation
Objective Data: temperature temperature room temperature environment and make it more • Document all the
38.5 degrees within the • Provide a tepid comfortable for the patient. findings and the
• Vital signs as Celsius, flushed normal sponge bath • Use the antipyretic medication to medication given.
follow: skin, profuse range. • Encourage the patient stimulate the hypothalamus and
Temp: 38.5 sweating, weak to increase oral fluid normalize the body temperature.
Pulse: 40 bpm pulse. intake as tolerated, • To facilitate the body in cooling
• Sore throat and/or provide down and provide comfort.
• Conjunctivitis- intravenous fluid • Excessive loss of water and salt
inflamed eyes replacement as due to fever require immediate
prescribed. replacement through encouraging
• Elevate the head of increased oral fluid intake or the
the bed. administration of parenteral fluids
• Head elevation helps improve the
Collaborative: expansion of the lungs, enabling
• Administer the the patient to breathe more
prescribed anti- effectively.
pyretic medications.
 6. Adolescent

Scenario: Adolescent suffering from Bulimia Nervosa

Assessment Diagnosis Desired Interventions Rationales Evaluation

Outcomes
Subjective Data: • Imbalanced • Client Independent: • Prevent vomiting during or after • Document all the
• Self-induced Nutrition: Less verbalized • Supervise the patient eating patient’s behaviour
vomiting, than body understanding during mealtimes and • To prevent self-induced vomiting pattern toward
verbalized by requirements of nutritional for a specified period • Among patients with bulimia eating
mother related to self- needs after meals (usually nervosa, warning signs include • Observe for the
• Excessive laxative induced • Client will one hour) having more comorbid psychiatric changes with the
use vomiting and establish • Identify the patient’s symptoms and reporting a history habits of the
excessive usage dietary elimination patterns of sexual abuse. patient after
Objective Data: of laxative pattern with • Assess her suicide • Bulimic patients may include interventions
evidenced by caloric intake potential abuse of laxatives, emetics, and • Monitor the
• Body weight: 45kg 15% below adequate to • Outline the risks of diuretics. patient’s changes in
• Pale conjunctiva normal range regain/ laxative, emetic, and • Malnutrition is a mood- altering body weight and if
and mucus body weight maintain an diuretic abuse of the condition, leading to depression consistency is
membranes and excessive appropriate patient and agitation, and affecting applied
• Excessive loss of loss of hair. weight • Establish a minimum cognitive function and decision • Document all the
hair • Client will weight goal and daily making. Improved nutritional findings and the
demonstrate nutritional status enhances thinking ability, medication/therapy
weight gain requirements allowing initiation of psychological given.
toward the • Provide smaller meals work.
individually and supplemental • Gastric dilation may occur if
expected meals and snacks as refeeding is too rapid following a
range appropriate period of starvation dieting. Note:
• Maintain regular Patient may feel bloated for 3-6
weighing schedule, weeks while the body adjusts to
such as Monday and food intake.
Friday before • Provides an accurate ongoing
breakfast in the same record of weight loss or gain. Also
 attire, and graph diminishes obsessing about
results changes in weight.
Collaborative: • Use in counterproductive because
• Avoid giving laxatives they may be used by the patient
• Administer to rid of the body of food and
supplemental calories
nutrition as • Total Parenteral Nutrition (TPN)
appropriate may be required for life-
• Administer threatening situation; however,
cyproheptadine enteral feedings are preferred
(Periactin) as because they preserve
indicated gastrointestinal function and
• Assist with reduce atrophy of the gut.
Electroconvulsive • A serotonin and histamine
Therapy (ECT) if antagonist that may be used in
indicated. Discuss high doses to stimulate the
reasons for use and appetite, decrease preoccupation
help the patient to with food, and combat depression.
understand that this Does not appear to have serious
is not punishment. side effects, although decreased
mental alertness may occur
• In rare and difficult cases in which
malnutrition is severe and life-
threatening, a short-term ECT
series may enable patient to begin
eating and become accessible to
psychotherapy.