A Nursing Care Plan on

Imbalance Nutrition Less Than Body Requirements

_________________________________________

A Nursing Care Plan Presented to

the Faculty of Nursing Department

Mrs. Ma. Catherine Belarma, RN, MN

________________________________________

In Partial Fulfillment on the

Requirements in NCM 209
Pediatric Nursing Rotation

By
Noahdel M. delos Reyes, St.N
BSN-2H

March 26, 2020

Name of Patient: ____________M.W.D.V__________________ Age/Sex: __10/M___ Room/Bed#: __205-1__
CC: _________Soar throat___________________________ Physician: ________Dr. Del Valle________
Diagnosis: _____________________________________________________________________________
D/T CUES NEE NURSING PATIENT INTERVENTIO IMPLE- EVALUATION
D DIAGNOSIS OUTCOME N MENTATION
M Subjective: N Imbalance nutrition less At the end of 4 hrs Monitor vital 9 03/24/20
A “Dili siya U than body requirements nursing case the signs @
R ganahan T related to difficulty in client would be R: To establish 2:30 PM
C mukaon og R swallowing as able to: baseline data
H muinom I evidenced by insufficient “GOAL PARTIALLY
kay sakit T interest in food a. show Advise client to MET”
2 daw iyang I interest in give soft foods 5
4 tutunlan” O Rationale: food and eat R: Soft foods After 4 hrs of nursing
as N Soar throat may cause atleast 1 are easy to care the client has:
2 verbalized A lack of desire to eat and meal or swallow
0 by the L drink due to level of pain more a. verbalized
2 patient with swallowing. While throughout Ask patient what 3 ” nakakaon na
0 - painful, drinking water is the day food he/she siya pero dili
Objective important to avoid b. complete prefer kayo daghan”
@ -Difficulty M dehydration as well as taking 3 to 5 R: It may
in E eating to maintain health full glasses increase the b. finish 1 and a
10:30 swallowing T and to avoid of water or appetite half glass of
-Refuses A malnutrition. more water
AM to eat B c. state Tell the client to c. state pain
-Fever O Reference: improvemen gargle warm 2 from 7/10 to
-Dryness L Hayes, K., and Asher, t from pain saltwater 6/10
of skin I B.F (2020). Health scale of 7/10 consisting of 4-8
-Scratchy C Complication to 5/10 oz of water with
voice Associated with Swollen quarter tsp. of
-Enlarge Tonsils. salt
lymph www.verywellhealth.com R: It will soothe
nodes scratchy throat.
-Grimace Salt pulls the
face mucus out of
observed wollen, inflamed
-Pain scale tissue and help
noted 7/10 relives
 discomfort
Vital signs
T: 38.4 °C Give medication
CR: 80 as physician
bpm ordered 6
PR: 75 R: For faster
bpm recovery
RR: 20
Give cold foods
such as
popsicles, cold 4
water and
smoothies
R: It will give
temporary pain
relief

Advise patient to
avoid hard foods 7
such as
crackers and
cookies
R: It may cause
irritation and
may scratch you
throat

Provide a quiet
environment in 8
order to give
client’s comfort
and rest
R: Resting will
allow the body
to fight off viral
and bacterial
infection

Observe non
 verbalization
cues that 1
indicates pain
such as grimace
face and crying
R: It will indicate
the severity of
pain and it may
needed further
assessment

Avoid talking so
long to the
patient 10
R: Raising of
voice may
cause the risk of
throat irritation

Noahdel M. delos
Reyes, St.N

A Nursing Care Plan on

Ineffective Airway Clearance
_________________________________________

A Nursing Care Plan Presented to

 the Faculty of Nursing Department

Mrs. Ma. Catherine Belarma, RN, MN

________________________________________

In Partial Fulfillment on the

Requirements in NCM 209
Pediatric Nursing Rotation

By
Noahdel M. delos Reyes, St.N
BSN-2H

March 26, 2020

Name of Patient: ____________M.T.S__________________ Age/Sex: __8/F___ Room/Bed#: __205-1__

CC: _________Soar throat___________________________ Physician: ________Dr. Guiyab________
Diagnosis: _____________________________________________________________________________
D/T CUES NEE NURSING PATIENT INTERVENTIO IMPLE- EVALUATION
D DIAGNOSIS OUTCOME N MENTATION
 M Subjective: S Disturbed sleep pattern At the end of 4 hrs Elevate head 2 03/25/20
A “Mura L related to prolonged nursing case the part @
R siyag E discomfort as evidence by client would be R: It will help 10:30 PM
C maglisod E inflammation of tonsils able to: client to breath
H og P easily while “GOAL PARTIALLY
ginhawa Rationale: a. identifies sleeping MET”
2 kung R Tonsils may grow to be food
5 matulog. E large relative to the size of needed to Monitor vital 9 After 4 hrs of
Sige pud S child’s airway. inflamed be given in signs nursing care the
2 siyag T and infective glands may order to R: To establish client has:
0 ingon na grow to be larger, thus lessen the baseline data
2 sakit iyang causing more blockage. pain a. verbalized
0 tutunlan” During the episode of b. apply side Advise to sleep 1 “mas mayo
as blockage, the child may lying in side lying diay ang
@ verbalized look as if it is trying to position in position lugaw kaysa
by the breath but no air is being sleeping R: It is easy to kan-on aron
8:30 patient exchange and often c. state pain breath in a side dili musamot
conclude period of scale from lying position og kasakit
PM Objective: awakening and 8/10 to 6/10 than supine ang tutunlan
-Swollen compensation of lack of sa akoang
tonsils breathing Give medication anak”
-Tender as physician 5 b. maintained
lymph Reference: ordered side lying
nodes Stanford Children’s Health R: For faster position
-Crying (2020). Obstructive Sleep recovery when
while Apnea sleeping
touching www.stanfordchildrens.or Provide a quite c. stated pain
the neck g environment 7 scale is still
-Fever R: Plenty of rest 8/10
-Restless is needed to
-Mouth allow the body
breather fight viral and
observe bacterial
while infections
sleeping
-Pain scale Advise client to
8/10 increase
humidifier 8
Vital signs R:Humidifier will
T: 38.4 °C prevent the
CR: 73 growth of
bpm bacteria
PR: 75
bpm Tell the client to
RR: 21 gargle warm
saltwater 3
consisting of 4-8
oz of water with
quarter tsp. of
salt
R: It will soothe
scratchy throat.
Salt pulls the
mucus out of
wollen, inflamed
tissue and help
relives
discomfort

Give cold foods

such as 4
popsicles, cold
water and
smoothies
R: It will give
temporary pain
relief

Advise patient to
avoid hard foods
such as 6
crackers and
cookies
R: It may cause
irritation and
may scratch you
throat
Observe non
verbalization
cues that 10
indicates pain
such as grimace
face and crying
R: It will indicate
the severity of
pain and it may
needed further
assessment

Noahdel delos
Reyes, St.N