NIC Airway Management Evaluation
Provides information about increasing airway obstruction. Lying down may cause epiglottis to fall backward, causing airway obstruction. Leads to airway spasms and obstruction. Promotes oxygenation of tissues and prevents hypoxemia. obstruction present and respiratory failure and asphyxia imminent. information and support for parents who are not familiar with procedures. Prepares parents with information of what to expect. Has goal been met Not met Partially met Describe status of child's...
Flow Chart For Bronchopulmonary Dysplasia
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Impaired Social Interaction
Related to Limited physical mobility. Defining Characteristics Specify change in pattern of interaction, lengthy treatment and immobilization, boredom, inability to engage in usual activities for age group, environment that lacks diversion. Goal Infant will experience adequate social interaction by date and time to evaluate . Outcome Criteria V Parent stays with infant and provides social interaction. V Infant responds positively to parental interaction. V Infant is included in family...
Additional Nursing Diagnoses Risk For Infection
Related to Inadequate primary defenses broken skin specify where . Defining Characteristics None, as this is a potential diagnoses. Goal Child will not experience any infection by date time to evaluate . Outcome Criteria V Site will be clean and dry, without redness, edema, drainage, or odor. V Child's temperature will be lt 101 F. NOC Risk Detection Assess temperature q 4 hours. Monitor lab work as obtained. Wash hands before and after providing care for patient. Teach family and child to wash...
Additional Nursing Diagnoses Deficient Knowledge
Related to Lack of exposure to information about disorder. Defining Characteristics Specify expressed need for information about continuous medical regimen to control renal bladder infection and measures to prevent infection. Goal Clients will obtain information about child's illness and treatment by date and time to evaluate . Outcome Criteria V Clients verbalize understanding of illness and treatment regimen. NOC Knowledge Disease Process Assess parents' and child's Provides basic...
Flow Chart For Kawasaki Disease
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Anticipatory Grieving
Related to Potential loss of significant other by parents, perceived potential loss of physiopsychosocial well-being by child. Prevents transmission of microorganisms as disease increases susceptibility to infection. Prevents transmission of microorganisms to child. Stasis of secretions provide medium for infection. Prevents exposure to infectious agents. antibiotics, that are often prescribed as a preventive measure. Specify drug action. Prevents any infection that will compromise respiratory...
NOC Comfort Level
Assess verbal and nonverbal Provides information about pain behavior, type and location and as a basis for analgesic severity of pain depending on age therapy. Administer analgesic based on pain Reduces pain and promotes rest assessment and before pain becomes to reduce stimuli and severe specify . restlessness action of Place in a comfortable position Promotes comfort and decreases avoid unnecessary movement or bladder spasms that cause manipulation of suprapubic pain. Administer antispasmodic...
NOC Knowledge Treatment Regimen
Teach parents on the administration of prescribed medications specify . Teach parents the signs and symptoms of respiratory distress specify . Instruct parents on the importance of rest and good nutrition, to prevent illness. provide care for the hospitalized child at a level they are comfortable with and within the constraints of necessary treatments. Teach parents, child, and family members, as applicable, on good handwashing techniques and the proper disposal of soiled tissues, and so forth....
Chapter 59 Wilms Tumor Introduction
Wilms' tumor or nephroblastoma is identified as the most common pediatric malignant renal tumor in children. Incidence of Wilms' tumor is slightly less frequent in boys than in girls. The average age at diagnosis with unilateral tumors is 41.5 months and with bilateral tumors is 29.5 months. Children with Wilms' tumor may have associated anomalies and chromosomal abnormalities, such as aniridia congenital absence of the iris hypospadias cryptorchidism Beckwith-Wiedemann syndrome Denys-Drash...
Flow Chart For Asthma
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Additional Nursing Diagnoses Activity Intolerance
Defining Characteristics Specify presence of circulatory respiratory problem, verbal complaint of fatigue or weakness, needs to rest after short period of play. Related to Imbalance between oxygen supply and demand. Defining Characteristics Abnormal heart rate or blood pressure response to activity, exertional dyspnea specify . Goal Child will tolerate increased activity. Outcome Criteria V Specify for this child the activity level that is optimal within the limitations of the congenital heart...
Risk For Aspiration
Related to Presence of tracheostomy or endotracheal tube. Defining Characteristics Specify impaired swallowing, vomiting, choking. Goal Client will not aspirate by date time to evaluate . Outcome Criteria V Client swallows meals without choking, coughing, or changing color. NOC Risk Control Assess ability to swallow, type of Provides information about food consistency solid or formula , age of child. Offer small amounts of liquids initially and follow with increases as tolerated add cereal to...
Interrupted Family Processes
Defining Characteristics Specify family system unable to meet physical, emotional needs of its members inability to express or accept wide range of feelings family unable to deal with or adapt to chronic illness of child in a constructive manner excessive involvement with ill child by parents siblings evidence of marital and social discord exhibited by parents guilt expressed by parents siblings irritability as a response to the ill child lack of support from family friends. Goal Family will...
NURSING DIAGNOSIS 1 Ineffective Airway Clearance
Related to Bronchospasm and increased pulmonary secretions. Defining Characteristics Shallow respirations with expiratory wheeze, respiratory rate 34, SaO2 88 , peak flow 200L min after medications. Goal Client will maintain a clear airway throughout admission. Outcome Criteria V Respiratory rate less than 24, lungs clear to auscultation, SaO2 greater than 95 . NOC Respiratory Status Ventilation Assess respirations for rate count one full minute , pattern depth, and ease, auscultate lung...
Risk For Deficient Fluid Volume 1
Defining Characteristics Specify vomiting, diarrhea, excessive renal excretion, dry skin and mucous membranes, weight loss, decreased urinary output, altered intake, sunken fontanels in infant, decrease of tears and saliva, sunken soft eyeballs, nasogastric suction, fistula. Related to Factors influencing fluid needs. Defining Characteristics Specify hypermetabolic states, temperature elevation diaphoresis , increased insensible loss respirations, perspirations , failure to absorb or reabsorb...
Flow Chart For Hepatitis
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Chapter 37 Croup Introduction
Laryngotracheobronchitis LTB is the most common form of croup. It is characterized by an acute viral infection of the larynx, trachea, and bronchi which causes obstruction below the level of the vocal cords. Spasmodic croup is croup of sudden onset, occurring mainly at night and characterized by laryngeal obstruction at the level of the vocal cords caused by viral infections or allergens. Both occur as a result of upper respiratory infection, edema, and spasms that cause respiratory distress in...
Constipation
Related to Less than adequate dietary intake and bulk. Defining Characteristics Specify frequency less than usual pattern, hard, dry formed stool, decreased bowel sounds, straining at stool, decreased amount of stool, change from human to cow's milk in infancy. Defining Characteristics Specify environmental changes school , stool withholding in young children, lack of privacy, inability of leisurely use of bathroom, not using bathroom when urge is felt by school-age children. Related to Less...
Risk For Infection
Related to Lack of completed immunizations. Defining Characteristics Infant child has not received all immunizations against childhood illnesses specify age and appropriate immunizations for age . Goal Infant child will not experience infection with preventable childhood illnesses by date time to evaluate . Outcome Criteria V Infant child receives all immunizations appropriate for age specify which immunizations and when they should be completed . V Infant child does not experience infection...
Deficient Knowledge Postoperative Home Care
Related to Lack of information about tonsillectomy and postoperative care. Defining Characteristics Specify, e.g., parents state or demonstrate lack of understanding of how to care for child after surgery. Goal Parents will gain the knowledge to care for the postoperative child safely at home by date time to evaluate . Outcome Criteria V Parents verbalize understanding of postoperative care information. V Parents demonstrate appropriate postoperative care of child specify, e.g., encouraging...
Ineffective Protection
Related to Specify drug therapy antineoplastics abnormal blood profile leukopenia, thrombocytopenia, anemia, coagulation treatments radiation . Defining Characteristics Specify altered clotting, bone marrow suppression, deficient immunity against infection, petechiae, bleeding from nose, gums, hematuria 25 of cases will display preoperatively , hemorrhagic cystitis a common side effect of cyclophosphamide . Goal Child will be protected from illness or injury by date and time to evaluate .
Deficient Fluid Volume
Related to Specify chemosensitive triggers medication, anesthesia, chemotherapy, toxins, increased ICP, inner ear disturbances, cerebral hypoxia, food intolerances, allergens, motion sickness. Defining Characteristics Specify nausea, vomiting, perspiration, weight loss or gain, pallor, dehydration, fluid and electrolyte imbalance, anxiety, hopelessness, loss of control, tachycardia, abdominal cramping, early morning vomiting ICP and metabolic disease , fever and diarrhea infection , decreased...
Chapter 21 Cardiac Catheterization Introduction
Cardiac catheterization is the insertion of a flexible catheter through a blood vessel most often the femoral vein into the heart for diagnostic and therapeutic purposes. It is usually combined with angiography when radiopaque contrast media is injected through the catheter and circulation is visualized on fluoroscopic monitors. Catheterization allows measurement of blood gases and pressures within chambers and great vessels measurement of cardiac output and detection of anatomic defects such...
NOC Family Coping Rhe
Assess stage of grief process, problems encountered, feelings regarding potential loss. Provide emotional and spiritual comfort in an accepting environment. Answer all questions honestly, clarify any misconceptions. responses and allow for their expression of feelings. Assist in identifying and using effective coping mechanisms and in accepting situations over which they have no control. Encourage parents to assist child with normal development and discipline. Allow child to talk about any...
NIC Anxiety Reduction Ken
Provides information that will enhance understanding of the defect to relieve anxiety. Provides rationale for surgery which includes voiding in a standing position with ability to direct stream, improve appearance of penis and preserve self-image, and to develop a sexually adequate penis. postoperative care and what to expect following surgery. Reduces anxiety and promotes ability to provide calm and supportive care. Relieves anxiety produced by fear caused by misinformation.
Chapter 20 Cardiovascular System Basic Care Plan Introduction
The cardiovascular system consists of the heart and a network of blood vessels arteries, veins, and capillaries. The heart is an efficient pumping mechanism that circulates oxygenated blood and nutrients to all parts of the body and provides a path for removal of wastes. Alteration in the function of the system may interfere with the client's well-being, thereby causing physical and psychosocial problems for both the affected child and family. Diseases of the cardiovascular system are...
Medical Care Lkc
Antipyretics acetaminophen to reduce fever Ibuprofen nonsteroidal anti-inflammatory for children 6 months to 12 years to reduce fever and inflammation. Antibiotics penicillin G to treat pneumococcal, streptococcal, or staphylococcal pneumonia Erythromycin, Trimethoprimsulfamethoxazole, Climadycin, Chloramphenicol, or cephalosporins for penicillin-allergic children. Oxygen Therapy treats hypoxemia, administered by oxygen tent or hood. Chest X-ray reveals patchy areas of consolidation in one lobe...
Impaired Oral Mucous Membrane
Defining Characteristics Specify stomatitis, oral ulcers, hyperemia, oral pain or discomfort, oral plaque. Prevents transmission of infective agents to the immunosuppressed child. To assess potential intestinal obstruction from vincristine-induced adynamic ileus. To prevent straining with bowel movements. Promotes understanding and cooperation. pathogens in the immunosuppressed child. associated with exposure or trauma to the abdominal site preoperatively and surgical site postoperatively....
Flow Chart For Appendicitis
Compression of blood vessels Ischemia Ulceration of epithelial lining of appendix Perforation of appendix Abscess of appendix site Rupture of appendix Surgical drainage of peritoneal cavity Abdominal decompression Peritonitis Intestinal obstruction Hypovolemic shock COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved. COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved. COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved. STAT Ref Online Electronic Medical...
Chapter 310 Tonsillitis Introduction
Tonsillitis is an infection of the tonsils, which consist of pairs of lymph tissue in the nasal and oropharyngeal passages. Bacterial or viral pharyngitis usually precedes infection of the tonsils. Inflammation and edema of the tonsillar tissue creates difficulty swallowing and talking, and forces the child to breathe through the mouth. Advanced infection can lead to cellulitis in adjacent tissue or formation of an abscess which may require drainage. The tonsils removed during a tonsillectomy...
Disorganized Infant Behavior
Related to Environmental stimulation. Defining Characteristics Specify, e.g., alterations in heart rate, respirations, color changes, erratic body movements, difficulty with feedings or prolonged periods of wakefulness. Goal Infant will display increased organization of behavior by date time to evaluate . Outcome Criteria V Infant demonstrates quiet alert state and ability to habituate to environmental stimuli. V Color changes with handling and movement are decreased. V Demonstrates smoother...
Additional Nursing Diagnoses Risk For Aspiration
Related to Increased intragastric pressure with an incompetent cardiac sphincter. Defining Characteristics Specify laryngospasm, choking, coughing, apnea, cyanosis, wheezing, pneumonitis. Goal Client will not aspirate by date and time to evaluate . Outcome Criteria V Absence of aspiration with breathing pattern maintained at baseline parameters specify . V Absence of recurrent pulmonary infection. NOC Risk Control Assess respiratory status for rate, depth and ease, breath sounds before and...
Impaired Urinary Elimination
Related to Specify mechanical trauma urethroplasty . Defining Characteristics Specify dysuria, frequency, urgency, retention, bladder spasms, inadequate output, edema of the urethra. Goal Client will experience improved urinary elimination by date and time to evaluate . Outcome Criteria V Client voids through new or corrected urinary meatus after catheter is removed. V Unable to palpate bladder after voiding. NOC Urinary Elimination Provides information and skill in caring and maintaining...
Additional Nursing Diagnoses Pain 1
Related to Inflammatory process dry mucous membranes, conjunctivitis, pharyngitis, fever, joint pain, swollen hands and feet . Defining Characteristics Specify crying, extreme irritability, refusal to play, cries when being touched or moved, increased rating on pain scale. Goal Child will experience less pain by date time to evaluate . V Specify, e.g., client is not crying, is playing, has relaxed facial features, allows touch, pain rating is less than before interventions give number . Assess...
Compromised Family Coping
Defining Characteristics Specify family expresses concern and fear about infant's apnea episodes, displays protective behavior disproportionate to infant's need to grow and develop, describes a preoccupation with monitoring of infant apnea, chronic anxiety. Goal Family will demonstrate adequate coping by date time to evaluate . Outcome Criteria V Family members are able to express feelings and needs to each other. V Family members identify three healthy coping mechanisms.
Impaired Home Maintenance
Related to Complexity of home care management of cystic fibrosis patient. Defining Characteristics Specify frequent exacerbations of respiratory infections inadequate understanding of illness and home care components child not functioning up to full potential in terms of growth and development, independence issues stressors within family relationships. Goal Family will provide a safe, hygienic home for ill child by date time to evaluate . Reinforces roles and reduces stress in family members....
Flow Chart For Nephrotic Syndrome
Provides safety measure to prevent complications in a child that is immunosuppressive. Prevents risk of infection that may precipitate a relapse. Positive reinforcement enhances desire to learn new skills. Promotes return to usual patterns of living. disease process and importance of compliance with therapy to prevent exacerbation. COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved. COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved. COPYRIGHT 2005 by Thomson Delmar...
Deficient Knowledge Parents Prevention Of Om
Related to Specify, e.g., lack of information lack of recall of information misinterpreted information. Defining Characteristics Specify, e.g., parents allow smoking in the home so child is exposed to passive smoke infant is bottle-fed and sometimes the infant lies flat with the bottle propped. Goal Parents will gain knowledge about prevention of OM by date time to evaluate . Outcome Criteria V Parents verbalize understanding of OM. V Parents verbalize understanding of 3 factors that may...
Flow Chart For Cryptorchidism
Prevents contamination of wound and risk of infection. Prevents or treats infection by preventing synthesis of cell wall of microorganisms. surgical area and prevents contamination. COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved.
Chapter 56 Cryptorchidism Introduction
Undescended testes cryptorchidism is a condition present at birth in which one or both testes fail to descend through the inguinal canal into the scrotal sac. The testes usually descend spontaneously by 1 year of age. If not, a child may receive human chorionic gonadotropin therapy or surgery orchiopexy performed between 1 to 2 years of age. Surgery prevents damage to the testes that may be affected by exposure to a higher temperature in the abdomen. Repair at a younger age also prevents the...
Chest Structure And Bronchopulmonary Movement
Chest shape and anteroposterior diameter Infant rounded chest where diameter equals transverse diameter School-age changes gradually to lateral diameter ratio of 1 2 or 5 7 as chest assumes a more flattened anteroposterior diameter with growth. Narrow, smaller lumen of airway system with increased airway resistance until age of five years. Ability to respond to irritating stimuli by age 4 to 5 months as smooth muscle develops in airways, gradually reaching smooth muscle development of an adult...
Play And Socialization
0 to 4 months Stares at environment, smiles indiscriminately or responsively, enjoys having others around, recognizes familiar faces, determines that face is unfamiliar and freezes gaze, establishes cycle for sleep and awake periods 0 to 1 month, prefers to look at faces, at black and white geometric designs, able to follow objects in line of vision 2 to 4 months, follows objects 180 , turns head to look for voices and sounds. 4 to 8 months Self-centered, begins to be fearful of strangers 4 to...
Ineffective Breathing Pattern
Defining Characteristics Specify shortness of breath, tachypnea, fremitus. Related to Decreased lung expansion. Defining Characteristics Specify apnea, dyspnea, respiratory depth changes. Related to Tracheobronchial obstruction. Defining Characteristics Specify dyspnea, head bobbing in infant, drooling, tachypnea, abnormal arterial blood gases, cyanosis skin, circumoral, mucous membranes , nasal flaring, respiratory depth changes, use of accessory muscles and retractions, altered chest...
Flow Chart For Cystic Fibrosis
Dehydration of exocrine gland secretions Electrolyte imbalance Dehydration tastes sally COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved.
Flow Chart For Inflammatory Bowel Disease
COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved. COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved. COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved. STAT Ref Online Electronic Medical Library 5 5 2006 6 51 38 AM PST GMT -08 00 Delmar's Pediatric Nursing Care Plans - 3rd Ed. 2005 12 21 2006 6 01 08 PM PST GMT -08 00 123 amp docid 36 DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. 2005 UNIT 4 - GASTROINTESTINAL SYSTEM CHAPTER 4.7 - INFLAMMATORY BOWEL...
NOC Parenting
Assess parents for achievement of developmental tasks of self and understanding of child's growth and development how they are bonded and attached to child how they interpret and respond to child how they accept and support child how they meet child's social, psycho-logical and physical needs. Provide a child nurturing role model for parents to emulate. Praise parents for their participation in child's care, tell them that they are giving good care to child. Include parents in planning care and...
NIC Infection Control
Indicates persistence of streptococcal infection. microorganism and sensitivity to specific antibiotic therapy. Destroys microbial agents by preventing cell wall synthesis and prevents transmission to family members. Promotes parental understanding and prevents development of super-infection. microorganisms to others or reinfection. Prevents respiratory infections in the susceptible child. Indicates infection and provides for early intervention.
Flow Chart For Glomerulonephritis
Post-streptococcal infection group A, beta-he molytic Release of material from the organism into the circulation tantigen Proliferation of endothelial cells lining glomerulus and cells behveen endothelium and Swelling of capillary membrane and infiltration with leukocytes Increased permeability of base membrane Occlusion of the capillaries of glomeruli Decreased glomerular filtration rate Decreased ability to fomi filtrate from Retention of water and sodium Reduced circulatory volume...
Risk For Suffocation
Defining Characteristics Specify supraglottic edema obstruction dysphasia hypoxia cyanosis extreme anxiety, with struggle to breathe. Goal Child will not experience suffocation by date time to evaluate . Outcome Criteria V Preventive measures taken to ensure patent airway. V Child's airway remains open either naturally or by means of ET tube or tracheostomy. NOC Risk Control Assess for changes in skin color from pallor to cyanosis, severe dyspnea and sternal and intercostal retractions,...