NURSING CARE PLAN FOR MASTER.

SHYNE WITH ALL

ASSESSMEN
T
Subjective
data
Mother says
My child is
having
breathing
difficulty

DIAGNOSIS

1) Ineffective
breathing
pattern
related to
pathological

GOAL

INTERVENTION

RATIONALE

IMPLEMENTATION

Childs
breathin
g
pattern
remains
normal

Assess the breathing pattern

of the child

To plan the care

effectively

Assessed and found

out that the child was
having severe
breathing difficulty
and the respiratory
rate was 60b/m, use
of accessory muscles.

Auscultate lung fields,

noting areas of
decreased/absent airflow
and adventitious breath
sounds, e.g., crackles,
wheezes

Decreased airflow
Auscultated and
occurs in areas
consolidated with found out that the
child was having
fluid. Bronchial
crackles
breath sounds
(normal over
bronchus) can
also occur in
consolidated
areas. Crackles,
rhonchi, and
wheezes are heard
on inspiration
and/or expiration
in response to
fluid

changes in
Objective data
Respiratory
rate 60 b/m
crackles
Use of
accessory
muscles
Laboured
breathing
Inter costal
retraction
Spo2 80% on
room air

the alveoli
as evidenced
by increased
rate of
respiration,
crackles,
decrease in
Spo2.

EVALUATIO
N
Baby became
sick and was
on oxygen.

Elevate head of bed,

change position
frequently.

Assist patient with

frequent deep-breathing
exercises.

accumulation,
thick secretions,
and airway
spasm/obstruction
.
Lowers
diaphragm,
promoting chest
expansion,
aeration of lung
segments,
mobilization and
expectoration of
secretions.
Deep breathing
facilitates
maximum
expansion of the
lungs/smaller
airways. Coughing
is a natural selfcleaning
mechanism,
assisting the cilia to
maintain patent
airways. Splinting
reduces chest
discomfort, and an
upright position

Head up position
was provided to the
child .

favors deeper, more

forceful cough
effort.

Demonstrate/help patient
learn to perform activity,
e.g., splinting chest and
effective coughing while
in upright position.
Suction as indicated (e.g.,
frequent or sustained
cough, adventitious breath
sounds, desaturation
related to airway
secretions).

Force fluids to at least

3000 mL/day (unless
contraindicated, as in
heart failure). Offer
warm, rather than cold,
fluids.

Assist with/monitor

Stimulates cough
or mechanically
clears airway in
patient who is
unable to do so
because of
ineffective cough
or decreased level
of consciousness.
Fluids (especially
warm liquids) aid
in mobilization and
expectoration of
secretions.
Facilitates
liquefaction and
removal of
secretions. Postural
drainage may not
be effective in
interstitial
pneumonias or
those causing
alveolar
exudate/destruction
. Coordination of

Chest physiotherapy
was performed on the
child

Fluid
supplementation was
given 120ml of fluid
over 6 hours to meet
the requirerment

Administered
nebulization with
salbutamol and
ipravent every 2 hour

effects of nebulizer
treatments and other
respiratory physiotherapy,
e.g., incentive spirometer,
IPPB, percussion,
postural drainage.
Perform treatments
between meals and limit
fluids when appropriate.

treatments/schedule
s and oral intake
reduces likelihood
of vomiting with
coughing,
expectorations.

Administer medications
as indicated: mucolytics,
expectorants,
bronchodilators,
analgesics.

Aids in reduction
of bronchospasm
and mobilization of
secretions.
Analgesics are
given to improve
cough effort by
reducing
discomfort, but
should be used
cautiously because
they can decrease
cough
effort/depress
respirations.

Administered
salbutamol in the
form of nebulisation

Fluids are required

Provide supplemental
fluids, e.g., IV, humidified to replace losses
(including
oxygen, and room
insensible) and aid
humidification.
in mobilization of

IV fluids were added

to correct the deficit

secretions. Note:
Some studies
indicate that room
humidification has
been found to
provide minimal
benefit and is
thought to increase
the risk of
transmitting
infection.

Impaired thermo
regulation
(hyperthermia)

Monitor serial chest xrays, ABGs, pulse

oximetry readings.

related to
pathological
changes as
evidenced by
increased
temperature

Assist with
bronchoscopy/thoracentes
is, if indicated.
2) subjective
data
Mother says
my child is

Child
maintain
normal
body

Assess vital sign changes,

e.g., increased
temperature/prolonged
fever, tachycardia,

Chest xray showed

right lower lobe
pneumonia

Follows progress
and effects of
disease
process/therapeutic
regimen, and
facilitates
necessary
alterations in
therapy.
Occasionally
needed to remove
mucous plugs,
drain purulent
secretions, and/or
prevent atelectasis
Elevated
temperature/prolon
ged fever increases

Assessedand found
that child was having
temperature 0f
101.4d F

Child was a
febrile since
fourth day of
admission

having fever

temperat
ure

orthostatic hypotension.

Objective
data:
Temperature:
101.4 degree
F
Coated tongue

Assess skin turgor, moisture

of mucous membranes (lips,
tongue).
Note reports of
nausea/vomiting.

metabolic rate and

fluid loss through
evaporation.
Orthostatic BP
changes and
increasing
tachycardia may
indicate systemic
fluid deficit.
Indirect indicators
of adequacy of
fluid volume,
although oral
mucous membranes
may be dry because
of mouth breathing
and supplemental
oxygen.

Presence of these
symptoms reduces
oral intake.

Assessed the skin

turgor and found to
have mild dryness of
the skin and coating
of the tongue

Monitored Intake and

output chart
Monitor intake and output
(I&O), noting color,
character of urine. Calculate
fluid balance. Be aware of

Provides
information about
adequacy of fluid
volume and

insensible losses. Weigh as

indicated.

replacement needs.

Force fluids to at least 3000

mL/day or as individually
appropriate.

Meets basic fluid

needs, reducing risk
of dehydration
Useful in reducing
fluid losses.
In presence of
reduced
intake/excessive
loss, use of
parenteral route
may correct/prevent
deficiency.

Activity intolerance
related to decreased
oxygenation and
decreased food intake
as evidenced by
decreased activity
level

Administer medications as
indicated, e.g., antipyretics

Useful in reducing
fluid losses.

Provide supplemental IV
fluids as necessary.

In presence of
reduced
intake/excessive
loss, use of
parenteral route
may correct/prevent
deficiency.

Subjective
data:
Mother says
child was less
active than

Child
maintain
the
normal

Evaluate patients response

to activity. Note reports of
dyspnea, increased
weakness/fatigue, and

Establishes
patients
capabilities/needs
and facilitates

Administered syrup.
Paracetamol (125/5)
4ml sos

Assessed and found

that the baby was
very much tired

Child remains
active
whenever he is
out of
symptoms

before

activity
level

Objective
data:
Decreased
activity
Lack of
interest in the
surroundings

changes in vital signs during

and after activities.

Provide a quiet
environment and limit
visitors during acute phase
as indicated. Encourage use
of stress management and
diversional activities as
appropriate.

choice of
interventions.

Reduces stress and

excess stimulation,
promoting rest

Comfortable
environment was
provided to the child

Child was on bed rest

when sick
Explain importance of rest
in treatment plan and
necessity for balancing
activities with rest.

Assist patient to assume

comfortable position for
rest/sleep.
Assist with self-care
activities as necessary.
Provide for progressive
increase in activities during
recovery phase. and
demand.

. Risk for Infection

Bedrest is
maintained during
acute phase to
decrease metabolic
demands, thus
conserving energy
for healing.
Activity restrictions
thereafter are
determined by
individual patient
response to activity
and resolution of
respiratory
insufficiency.
Patient may be
comfortable with

Childs activity was

planned in such a
manner that the child
energy was
conserved

related to
Inadequate
secondary defenses:
alterations in mature
WBCs (low
granulocyte and
abnormal
lymphocyte count),
increased number of
immature
lymphocytes;
immunosuppression
, bone marrow
suppression (effects
of
therapy/transplant)
Inadequate primary
defenses (stasis of
body fluids,
traumatized tissue)
Invasive procedures
Malnutrition;
chronic disease

head of bed
elevated, sleeping
in a chair, or
leaning forward on
overbed table with
pillow support.
Minimizes
exhaustion and
helps balance
oxygen supply and
demand.
Choice of
interventions
depends on the
underlying cause of
the problem.
Eliminates noxious
sights, tastes,
smells from the
Child
remains
free
from
infectio
n

Child was on high

dependency area
Place in a private room.
Limit visitors as indicated.
Prohibit live plants or
flowers. Restrict fresh fruits
and make sure they are
properly washed or peeled.
Coordinate patient care so
that leukemic patient
doesnt come in contact with
staff who also care for
patients with infections or

To protect the
patient from
potential sources of
pathogens or
infection. Bone
marrow
suppression,
neutropenia, and
chemotherapy
places the patient at
high risk for

Child was out

of symptoms
of infection

infectious diseases.

infection.

Require good hand washing

protocol for all personnel
and visitors.

Prevents crosscontamination and

reduces risk of
infection.
Although fever
may accompany
some forms of
chemotherapy,
progressive
hyperthermia
occurs in some
types of infections,
and fever
(unrelated to drugs
or blood products)
occurs in most
leukemia patients.
Septicemia may
occur without fever.

Closely monitor
temperature. Note
correlation between
temperature elevations and
chemotherapy treatments.
Observe for fever associated
with tachycardia,
hypotension, subtle mental
changes.

Prevent chilling. Force

fluids, administer tepid
sponge bath.

Helps reduce fever,

which contributes
to fluid imbalance,
discomfort, and
CNS
complications.

Prevents stasis of

Educated the mother

the need for strict
hand washing

Tepid sponging was

provided.

Child was on
continuous

Encourage frequent turning

and deep breathing.
Auscultate breath sounds,
noting crackles, rhonchi.
Inspect secretions for
changes in characteristics:
increased sputum production
or change in sputum color.
Observe urine for signs of
infection: cloudy, foulsmelling, or presence of
urgency or burning with
voids.

Handle patient gently. Keep

linens dry and wrinkle-free.
Inspect skin for tender,
erythematous areas; open
wounds. Cleanse skin with
antibacterial solutions.

respiratory
secretions, reducing
risk of atelectasis
or pneumonia.

Early intervention
is essential to
prevent sepsis in
immunosuppressed person.
Prevents sheet burn
and skin
excoriation.
May indicate local
infection. Open
wounds may not
produce pus
because of
insufficient number
of granulocytes.

monitoring

Child was given

comfortable
environment

Meticulous oral care

was provided and

Inspect oral mucous

membranes. Provide good
oral hygiene. Use a soft
toothbrush, sponge, or
swabs for frequent mouth
care.

The oral cavity is

an excellent
medium for growth
of organisms and is
susceptible to
ulceration and
bleeding.

candid mouth paint

was given as a
prophylaxis.

Avoid using indwelling

urinary catheters and giving
I.M. injections.
Provide thorough skin care
by keeping the patients skin
and perianal area clean,
apply mild lotion or creams
to keep the skin from drying
or cracking. Thoroughly
clean skin before all
invasive skin procedures.
Change IV tubing according
to your facilitys policy. Use
strict sterile technique and a
metal scalp vein needles
(metal butterfly needle)
when starting IV. If the
patient receives total
parenteral nutrition, give
scrupulous subclavian
catheter care.

These can provide

an avenue for
infection.
Additional
measures to avoid
infection.
IV sites can harbor
infection.
Additional measure
to avoid infection.
Promotes
cleanliness,
reducing risk of
perianal abscess;
enhances
circulation and
healing. Perianal
abscess can
contribute to
septicemia and
death in immune
compromised
patients.

Invasive procedures
were limited to
minimum. All efforts
were carried out to
prevent the chance of
breakdown of skin
integrity.

Promote good perianal

hygiene. Examine perianal
area at least daily during
acute illness. Provide sitz
baths, using Betadine or
Hibiclens if indicated. Avoid
rectal temperatures, use of
suppositories.

Coordinate procedures and

tests to allow for
uninterrupted rest periods.

Encourage increased intake

of foods high in protein and
fluids with adequate fiber.

Limit invasive procedures

(venipuncture and
injections) as possible.

Conserves energy
for healing, cellular
regeneration.

Promotes healing
and prevents
dehydration.
Constipation
potentiates
retention of toxins
and risk of rectal
irritation or tissue
injury.

Break in skin could

provide an entry for
pathogenic or
potentially lethal
organisms. Use of
central venous lines
(tunneled catheter

All activities were

performed at one
time as tolerated.

Encouraged to
increase the intake
but the child was not
taking the food.

or implanted port)
can effectively
reduce need for
frequent invasive
procedures and risk
of infection. Myelo
suppression may be
cumulative in
nature, especially
when multiple drug
therapy (including
steroids) is
prescribed.

Monitor laboratory studies:

CBC, noting whether WBC
count falls or sudden
changes occur in
neutrophils;
Grams stain cultures and
sensitivity.
Review serial chest x-rays.

Monitor laboratory
studies:
Decreased numbers
of normal or mature
WBCs can result
from the disease
process or
chemotherapy,
compromising the
immune response
and increasing risk
of infection.
Verifies presence of
infections;
identifies specific
organisms and
appropriate therapy.

Monitored lab values

and recorded the
findings

Indicator of
development or
resolution of
respiratory
complications.

Prepare for and assist with

leukemia-specific treatments
such as chemotherapy,
radiation, and/or bone
marrow transplant.

Administer medications as
indicated:
antibiotics
Colony-stimulating factors:
sargramostim (Leukine).

Leukemia is
usually treated with
a combination of
these agents, each
requiring specific
safety precautions
for patient and care
providers.

Assisted with various

procedures.

Administer
medications as
indicated:
May be given
prophylactically or
to treat specific
infection.
Restores WBCs
destroyed by
chemotherapy and
reduces risk of
severe infection

Administered
medications as per
doctors order.

and death in certain

types of leukemia.

Avoid use of aspirincontaining antipyretics.

Provide nutritious diet, high

in protein and calories,
avoiding raw fruits,
vegetables, or uncooked
meats.

Aspirin can cause

gastric bleeding
and further
decrease platelet
count.

Proper nutrition
enhances immune
system. Minimizes
potential sources of
bacterial
contamination.

Salicylates were not

used.

Educated the mother

the significance of
nutritional didorders.