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Ø Health Perception/Management:
Former 32 week Premie with history of multiple occurrences of vomiting, respiratory
distress and pneumonia.
Recently diagnosed with GERD (Gastro-esophageal reflux disease).
Home meds include Cisapride, Zantac, Atrovent and Albuterol.
Parents expect that she will be in the hospital for approximately 5 days and will go home on her
prior feedings. They are unsure of the purpose and care of GT.
Ø Role/Relationship:
Parents accompany child to the unit.
Patient lives with parents and two older siblings, ages 3 and 5.
Both parents work, and patient goes to day care 5 days a week. They will be unable to stay with
the patient during her hospitalization.
Ø Nutrition/Metabolic:
Takes 4-5 oz. of Similac with Fe 5x/day plus 2-3 jars of strained food.
She vomits moderate amount soon after eating 2-3 x/day.
Current weight = 5 kg. She has fallen off the growth curve.
Ø Activity/Exercise:
Patient has become less active especially during occurrences of pneumonia.
Ø Cognitive/Perceptual:
Developmental milestones are at approximately a 6-month-old level.
Sits independently but does not crawl or pull self to standing.
Has no problem with hearing or vision.
Has not been connected with Early Intervention Services.
Nutritional/Metabolic
is the most affected functional health pattern for this patient at this period of time.
.
While all these nursing diagnoses are appropriate, for purposes of this exercise let’s use:
On the nursing care plan form write in the nursing diagnosis, identifying the defining
characteristics and related factors.
• The next step is to select nursing outcomes that can best affect this nursing diagnosis.
• Listed below are two appropriate nursing outcomes for this patient.
Select one of the above listed nursing outcomes for this care plan exercise, go to the
nursing care plan form and check the indicators that you think will best measure your
patient’s progress towards the outcome that you have chosen. You will need to rate your
patient’s current status for each indicator.
The following two Nursing Interventions are appropriate for this patient. Review the activities
listed below each NIC and select 5 that apply. Write these five on the nursing care plan in the
activity column.
NIC: Fluid Management–Activities 3
(,p.348)
• Weigh daily and monitor • Count or weigh diapers as • Maintain accurate intake and output
trends appropriate record
• Monitor hydration status • Monitor for indications of fluid • Monitor laboratory results relevant to
(e.g., moist mucous overload/retention (e.g., fluid retention (e.g., increased specific
membranes, adequacy of crackles, elevate CVP or gravity, increased BUN, decreased
pulses, and orthostatic pulmonary capillary wedge hematocrit, and increased urine
blood pressure), as pressure, edema, neck vein osmolality levels
appropriate distention, and ascites), as
appropriate
• Assess location and extent • Monitor vital signs, as • Insert urinary catheter, if appropriate
of edema, if present appropriate
• Monitor patient’s weight • Monitor hemodynamic status, • Monitor food/fluid ingested and
change before and after including CVP, MAP, PAP, and calculate daily caloric intake, as
dialysis, if appropriate PCWP, if available appropriate
• Administer IV therapy, as • Monitor nutrition status • Give fluids, as appropriate
prescribed
• Administer prescribed • Administer IV fluids at room • Distribute the fluid intake over 24 hr.,
diuretics, as appropriate temperature as appropriate
• Instruct patient on nothing • Administer prescribed • Promote oral intake (e.g., provide a
by mouth (NPO) status, as nasogastric replacement based drinking straw, offer fluids between
appropriate on output, as appropriate meals, and change ice water routinely),
as appropriate
• Encourage significant other • Offer snacks (e.g., frequent • Restrict free water intake in the
to assist patient with drinks and fresh fruits/fruit presence of dilutional hyponatremia
feedings, as appropriate juice), as appropriate with serum Na level below 130 mEq per
liter
• Monitor patient’s response • Consult physician, if signs and • Arrange availability of blood products
to prescribed electrolyte symptoms of fluid volume excess for transfusion, if necessary
therapy persist or worsen
• Administer blood products (e.g., • Prepare for administration of blood
platelets and fresh frozen products (e.g., check blood with patient
plasma), as appropriate identification and prepare infusion
setup), as appropriate
• Refer for diagnostic • Weigh patient at specified • Discuss possible causes of low body
workup to determine intervals, as appropriate weight
cause of being
underweight, as
appropriate
• Monitor for nausea and • Determine cause of nausea • Administer medications to reduce
vomiting and/or vomiting, and treat nausea and pain before eating, as
appropriately appropriate
• Monitor daily calories • Monitor serum albumin, • Encourage increased calorie intake
consumed lymphocyte, and electrolyte
levels
• Instruct on how to • Provide a variety of high- • Consider patient’s food
increase calorie intake calorie nutritious foods from preferences, as governed by
which to select personal choices and cultural and
religious preferences
• Provide oral care before • Provide rest periods, as • Ensure that patient is in a sitting
meals, as needed needed position before eating or feeding
• Assist with eating or • Provide foods appropriate for • Create a pleasant, relaxing
feed patient, as patient: general diet, environment at mealtime
appropriate mechanical soft, blenderized
or commercial formula via
nasogastric or gastrostomy
tube, or total parental
nutrition, as ordered by
physician
• Serve food in a pleasant, • Discuss with patient and • Discuss with patient and family
attractive manner family socioeconomic factors perceptions or factors interfering
contributing to inadequate with ability or desire to eat
nutrition
• Refer to community • Teach patient and family • Teach patient and family how to buy
agencies that can assist meal planning, as appropriate low-cot, nutritious foods, as
in acquiring food, as appropriate
appropriate
• Reward patient for • Chart weight gain progress • Encourage attendance at support
weight gain and post in a strategic groups, as appropriate
location
• Weigh patient at • Monitor trends in weight loss • Monitor type and amount of usual
specified intervals and gain exercise
• Monitor patient’s • Monitor parent/child • Monitor environment where eating
emotional response when interactions during feeding, occurs
placed in situations that as appropriate
involve food and eating
• Schedule treatments and • Monitor for dry, flaky skin • Monitor skin turgor, as appropriate
procedures at times with depigmentation
other than feeding times
• Monitor for dry, thin • Monitor gums for swelling, • Monitor for nausea and vomiting
hair that is easy to pluck sponginess, receding, and
increased bleeding
• Monitor skinfold • Monitor albumin, total • Monitor lymphocyte and electrolyte
measurements;triceps protein, hemaglobin, and levels
skinfold, midarm muscle hematocrit levels
circumference, and
midarm circumference
• Monitor food • Monitor growth and • Monitor energy level, malaise,
preferences and choices development fatigue, and weakness
• Monitor for pale, • Monitor caloric and nutrient • Monitor for spoon-shaped, brittle,
reddened, and dry intake ridged nails
conjunctival tissue
• Monitor for redness, • Note any sores, edema, • Note if tongue is scarlet, magenta,
swelling, and cracking of hyperemic and hypertrophic or raw
mouth/lips papillai of the tongue and oral
cavity
• Note significant changes • Initiate a dietary consult, as • Determine whether the patient
in nutritional status and appropriate needs a special diet
initiate treatments, as
appropriate
• Provide optimal • Provide nutritional food and
environmental conditions fluid, as appropriate
at mealtime
Congratulations!
You have successfully completed your first nursing care plan using the standard nursing language
vocabularies of NANDA, NOC, and NIC.
1. If you wish to received CE for this educational activity, please complete the evaluation form and
return along with $10 to:
Carol Williams, MS, RN, C
Educational Services for Nursing
University of Michigan Health System
300 North Ingalls , 6B12
Ann Arbor, Michigan 48109-0436
NOCs (Outcomes)
Measurement Scale Score:
1 = Not adequate
2 = Slightly adequate
Nutritional 3 = Moderately adequate
4 = Substantially adequate
Status:
5 = Totally adequate
Food & ❏ Oral food intake
Liquid ❏ Tube feeding intake
Intake ❏ Oral fluid intake
❏ IV fluid intake
DATE/TIME
INITIALS