NOC Coping

Assess effectiveness of family coping methods family interactions and expectations related to long-term, developmental level of family response of siblings knowledge and use of support systems and resources presence of guilt, anxiety, overprotective and or overindulgent behaviors. Encourage family members to express stressors and explore solutions responsibly. Assist family in establishing short-and long-term goals for child and in integrating child into family activities include participation...

Flow Chart For Congenital Hip Dysplasia

Genetic factor In utero development Defective acetabulum Femoral head is out of joint and positioned posterior and superior to acetabulum intrauterine malposition Breech birth Cesanean birth Liga ment-rela King hormone by mother prior to birth Affected leg shorter in older infant and child Inability to abduct leg Femoral head in contact with acetabulum Splinting of hip with femur in acetabulum Delayed walking with a limp Contracture of hip abductor and flexor muscles Pavlik harness Double...

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...

NOC Knowledge Treatment Procedure

Assess knowledge of causes of hernia, surgical procedure performed, willingness and interest to implement treatment regimen. appropriate with information and clear explanations in understandable language, include teaching aids and encourage questions. Inform to maintain incision dressing until it peels off and to apply diaper so that it does not cover incision. Teach to give sponge baths until incision heals. Encourage to hold infant when crying and to feed activity is not usually restricted...

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).

Medical Care

Pelvic X-ray reveals outward femoral displacement with upward slope of the roof of the acetabulum in infant child over 4 months of age. Ultrasound reveals cartilaginous head displacement in infant under 1 to 4 months of age. Ortolani Test a maneuver abducting the infant's leg that, in the event of hip dysplasia, causes the femoral head to enter the acetabulum and is identified by a click as this occurs. Barlow's Test a maneuver adducting the infant's leg that, in the event of hip dysplasia,...

Inflammatory Bowel Disease Introduction

Inflammatory bowel disease includes Crohn's disease and ulcerative colitis with similar signs and symptoms but with different intestinal pathology. Actual cause of either disease is unknown but they are associated with immunologic, nutritional, and infectious disturbances with psychogenic factors responsible for severity and exacerbation of the disease. Crohn's disease affects the small and or large intestine with the terminal ileus the most common site. It involves all layers of the bowel and...

Flow Chart For Sexually Transmitted Diseases

Spread of the organism along the mucosa point of enljy (urethra or Pelvic inflammatory disease as infection spreads or with recurrent infections site of inoculation (red, painless ulcer) Cutaneous rash of papules, macules, pustules Eventual healing with change in pigmentation (absence or increase) Meatal eiythema, urethral discharge and itching in male Eiythema, edema, congestion of cervix in female Polypoid mass with irregular surface on external genitalia arefls and genital tract in females...

Deficient Knowledge

Related to Lack of exposure to information about ongoing care. Defining Characteristics (Specify expressed request for information about medication regimen, causes of seizures and when to report to physician.) Goal Parents will obtain information about care of child by (date and time to evaluate). Outcome Criteria V Parents verbalize understanding of cause of seizures. V Parents verbalize correct medication plan for child. NOC Knowledge Treatment Regimen Assess parents' and child's perceptions...

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...

NIC Teaching Disease Process Evaluation

Provides early detection of disease and possible source of disease, and prevents potential spread of disease. Prevents transmission of the disease. Recovery requires extended period of time and support helps to ensure compliance with regimen. Promotes body's own use of natural defenses stress may further weaken those defenses. Reinforces teaching and promotes optimal caregiving. (Has goal been met Not met Partially met ) (Did parents verbalize understanding about tuberculosis and planned...

Hematologic Growth And Development Introduction

The hematologic system includes the blood (plasma and cells) and the blood-forming tissues organs (red bone marrow, lymph, lymph nodes, spleen, thymus, and tonsils). The cellular portion of the blood contains the erythrocytes (RBC), leukocytes (WBC), and thrombocytes (platelets). The plasma portion contains water and solutes, which include albumin, electrolytes, and proteins (clotting factors, fibrinogen, globulins, and antibodies). The system provides the body with specialized cells to...

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Kawasaki Disease Introduction

Kawasaki Disease, or mucocutaneous lymph node syndrome, is an acute vasculitis of unknown cause. Most cases occur in children less than 5 years of age. The disease is self-limiting, but about 20 of those affected will develop cardiac sequelae (most commonly dilatation of the coronary arteries resulting in coronary aneurysms). The disease occurs in 3 phases the acute phase is characterized by progressive inflammation of small blood vessels accompanied by high fever, inflammation of the pharynx,...

Disturbed Sensory Perception Visual

Related to (Specify altered sensory reception, transmission and or integration of neurologic disease or deficit, altered state of sense organ, inability to see partial or complete loss of sight .) Defining Characteristics (Specify change in behavior pattern, anxiety, change in usual responses to stimuli, visual distortions, reduced visual acuity, myopia, hyperopia, lazy eye, cross-eye, cataracts, glaucoma, trauma to eye, frequent injury by walking into objects.) Goal Client will experience...

Pain

Related to Increased pressure in the middle ear. Defining Characteristics (Specify e.g., infant is pulling at ear and crying, child states my ear hurts rate pain on an appropriate pain scale for age and development.) Goal Client will experience relief from pain by (date time to evaluate). Outcome Criteria V Child rates pain < (specify for scale used). V Infant does not pull at ear, is calm and not crying, pain rating is < (use a pain scale designed for infants). NOC Comfort Level...

NIC Surveillance Evaluation

(Has goal been met Not met Partially met ) children with symptoms related to cause of hydrocephalus. increasing ICP causing decreased respirations, increased blood pressure and pulse. Promotes drainage of CSF and reduces accumulation of CSF infant may not be able to lift and move head. Prevents injury to self during seizure activity caused by increased ICP and to treat apnea during seizure activity. Protects infant's head from trauma and neck from strain. Promotes knowledge of risk of...

NIC Pain Management

Provides information about pain caused by vasoocclusion resulting from RBC sickling, ischemia, and necrosis in soft tissue, joints, abdomen, back, or wherever occlusion occurs. Decreases stimuli that increase pain and promotes rest, decreases oxygen expenditure. Promotes comfort and prevents pain from movement. Provides information and rationale for treatment. Provides measures to control sickling, which results in pain.

NOC Risk Detection

Assess for signs of bleeding from any site as manifested in skin changes also, blood from nose, oral cavity, urinary or gastrointestinal tract, and factors that precipitate or Provides information indicating blood loss as tendency increases with therapy for aplastic anemia. Assess blood in urine with dipsticks and hematests (specify when). Protect child from trauma by padding bed and toys, using soft toothbrush and towels or swabs for cleaning mouth, avoiding rectal temperature and injections....

Nursing Care Plans And Individual Client Care Needs

This book is intended to facilitate the care planning process for nurses working with pediatric clients based on recognized nursing standards. Each of the nursing diagnoses is from NANDA's Taxonomy II (NANDA, 2003). The outcome criteria include the appropriate Nursing Outcome Classification (NOC) as well as prompts to assist the user in developing individualized outcomes. This text also contains suggested Nursing Intervention Classifications (NIC) for each nursing diagnosis in addition to...

NOC Self Care Bathing Hygiene Dressing Grooming Feeding Toileting

Assess abilities and level of care Provides information about and assistance. child's ability to perform Allow as much independence in ADL as Promotes independence and control possible but assist when needed. over daily personal care needs Encourage to perform own care and Promotes sense of accomplishment praise all accomplishments. and independence motivates to Position articles needed for care Promotes independence and allows within reach provide physical child access to aids to enhance aids...

Flow Chart For Spina Bifida

Promote expediency in treatment if a reaction occurs may prevent an allergic reaction. Prevent development of latex allergy prevent allergic reaction in those who are already sensitized. Promotes screening of all patients which may prevent severe allergic reactions in otherwise low-risk patients. COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved.

Common Nursing Diagnoses See Fluid Volume Excess

Related to (Specify compromised regulatory mechanisms, excessive sodium intake.) Defining Characteristics (Specify edema, weight gain, intake greater than output, blood pressure changes, altered electrolytes give data.) See IMBALANCED NUTRITION MORE THAN BODY REQUIREMENTS Related to Excessive intake in relationship to metabolic need. Defining Characteristics (Specify weight 10 over ideal for height and frame, dysfunctional eating pattern, hereditary predisposition provide data.) See INEFFECTIVE...

R

HIV infection Human immunodeficiency virus ADS Acquired immunodeficiency syndrome Opportunistic infections COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved. COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved. STAT Ref Online Electronic Medical Library

NOC Risk Control

Assess for change in breathing Indicates presence of respiratory pattern, color of mucus, infection. Promotes understanding of effect of activity on breathing and importance of rest to prevent fatigue. Measures to prevent fatigue while engaging in as near normal participation as possible. diminished breath sounds, ability to cough and raise secretions (specify frequency). Teach to avoid exposure to persons with respiratory infections isolate from infectious patients. Teach and use good...

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...

Additional Nursing Diagnoses Risk For Infection

Related to Chronic respiratory disease. Defining Characteristics (Specify reduced ciliary activity, lung damage, decreased lung capacity and accessory muscles' inability to move secretions, increased temperature, yellow or green sputum in increased amounts, diminished breath sounds presence of respiratory and suction of family membranes.) Goal Infant will not experience a respiratory infection by (date time to evaluate). Outcome Criteria V Temperature < 101 F, clear respiratory secretions,...

Hospitalized Child Introduction

Hospitalization of the child, whether it involves a short-term hospital admission, surgery, a follow-up evaluation, or repeated hospitalizations for a chronic illness or episode, creates a crisis for the child and family. Responses to hospitalization are related to the developmental level of the child but generally include fear of separation, loss of control, injury, and pain. The ease of transition from home to the hospital depends on how well the child has been prepared for it and how the...

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...

NIC Energy Management

Dyspnea and work of breathing over period of time exhausts the infant child's energy reserves affecting ability to rest, eat, drink. Conserves energy and prevents interruptions in rest. Promotes adequate rest and reduces stimuli to decrease fatigue. respiratory distress quiet play prevents excessive activity, which depletes energy and increases respirations. Promotes understanding of infant young child's response to respiratory distress and importance of rest and support to prevent fatigue....

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& docid 36 DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 4 - GASTROINTESTINAL SYSTEM CHAPTER 4.7 - INFLAMMATORY...

NIC Urinary Elimination Management Evaluation

(Has goal been met Not met Partially met ) Moves residual urine if unable to empty bladder completely. Establishes a routine for urinary elimination if this is a possibility. Ensures emptying of bladder to prevent incontinence and infection. continence by increasing bladder (action). Provides method for emptying bladder routinely or managing incontinence by use of collecting device connected to a closed system. Provides an alternate method of controlling incontinence although may be temporary....

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...

NOC Knowledge Disease Process

Assess knowledge of treatment of an infection, possible complications, extent of infection, and risk of spread. Inform parents of cause of the infection and manifestations to note including pain, redness, swelling, warmth of a localized infection and to report increasing temperature, enlarged lymph nodes in the region, and a red streak along the lymph pathway in a systemic infection. Administer antibiotics as ordered (specify), teaching parents about administration with dose, time, frequency,...

Guillainbarre Syndrome Introduction

Guillain-Barre syndrome (infectious polyneuritis) is an acute inflammation of the spinal and cranial nerves manifested by motor dysfunction that predominates over sensory dysfunction. The actual cause is unknown, but it is associated with a previously existing viral infection or vaccine administration. Neurologic symptoms include muscle cramps and paresthesia with weakness progressing to paralysis. The severity of the disease ranges from mild to severe with the course of the disease dependent...

Play

Play is described as the work of childhood. Children use play to learn about themselves and the world and also to cope with new or stressful events. Child development experts recognize play as a significant coping strategy for children. For example, children may use play as an outlet for self-expression, to manipulate experience, and to attempt to master the environment. Play provides the child with a measure of control over events and settings. Children's play also promotes social, cognitive,...

NOC Activity Tolerance

Assess for extreme weakness and fatigue ability to rest, sleep, and amount movement in bed. Disturb infant small child only when necessary, perform all care at one time instead of spreading over a long period of time. Schedule and provide rest periods in a quiet, comfortable environment (temperature and humidity). Allow quiet play with familiar toy while maintaining bed rest. Encourage parents to use measures to prevent fatigue in infant small child (holding and or rocking, feeding in small...

Cleft Lippalate Introduction

Cleft lip and or palate is a defect caused by failure of the soft and bony tissue to fuse in utero. They may occur singly or together and often occur with other congenital anomalies such as spina bifida, hydrocephalus, or cardiac defects. Treatment consists of surgical repair, usually of the lip first between 6 and 10 weeks of age, followed by the palate between 12 and 18 months of age. The surgical procedures are dependent on condition of the child and physician preference. Management involves...

Treatment For Sickle Cell Anemia

Hydration given for hemodilution to treat prevent sickle cell crisis. Analgesics to prevent treat pain crisis. Immunizations should receive all recommended childhood immunizations should also receive pneumococcal (at 2 years of age and a booster at 5 years of age) Haemophilus influenzae, type B (is given to all infants at 2 months of age) and meningococcal vaccine (at 2 years of age). Folate Replacement is given for the treatment of aplastic type of sickle cell crisis. Blood Transfusions packed...

NOC Social Involvement

Provide age appropriate toys to be used in bed while in a prone or sitting position depending on type of treatment and degree of immobilization. Provide exposure to other children by moving bed near areas of activity or near a window wheel on a stretcher, wheelchair, or stroller allow to walk with cast or brace if permitted. Encourage family and friends to visit or stay with child. boredom. Place toys and other articles within reach. Teach parents to include infant child in family activities....

Impaired Parenting

Related to (Specify unmet social and emotional maturation needs of parental figures, ineffective role modeling, lack of knowledge, situational crisis or incident.) Defining Characteristics (Specify lack of parental attachment behaviors, verbalization of resentment toward child and of role inadequacy, inattention to needs of child, noncompliance with health practices and medical care, inappropriate discipline practices, frequent accidents and illness of child, growth and development lag in...

Therapeutic Management

Chemotherapy and Radiation Therapy Protocol Favorable Histology vincristine and actinomycin-D (no radiation). Unfavorable Histology vincristine, actinomycin-D, cyclophosphamide, with radiation. Renal Angiogram reveals renal function and extent of involvement. Scans of Kidney, Liver, Bone reveals involvement of these organs if metastasis is present. Inferior Venacavagram reveals involvement adjacent to the vena cava if the tumor has grown to a large size. Erythrocyte Sedimentation Rate (ESR)...

Hivaids Introduction

Acquired immunodeficiency syndrome (AIDS) is caused by HIV (human immunodeficiency virus). HIV has been found in blood and bodily fluids (semen, saliva, vaginal secretions, urine, breast milk, and tears). Transmission of HIV can occur by 3 primary modes exposure by sexual contact, IV exposure to blood, or perinatal exposure from an HIV-infected mother to her infant. In children and adolescent age groups 3 populations have been identified 1) children exposed in utero from an infected mother 2)...

Bronchiolitis Introduction

Bronchiolitis is an acute viral inflammation of the lower respiratory tract involving the bronchioles and alveoli. Accumulated thick mucus, exudate, and cellular debris and the mucosal edema from the inflammatory process obstruct the smaller airways (bronchioles). This causes a reduction in expiration, air trapping, and hyperinflation of the alveoli. The obstruction interferes with gas exchange, and in severe cases causes hypoxemia and hypercapnia, which can lead to respiratory acidosis....

Sensory Deficits Introduction

Sensory deficits can lead to auditory or visual deprivation and affect the child's ability to interact with the environment. Cognitive, perceptive, communicative, and social skills may all be affected. Vision disorders are common in children with the most prevalent problems of a refractive type (myopia or hyperopia) and others that include amblyopia, strabismus, cataracts, and glaucoma. Eye injury may occur as a result of trauma from blunt or sharp objects, or from infection resulting in...

Additional Nursing Diagnoses Pain

Related to Biologic, physical, psychological injuring agents (specify). Defining Characteristics (Specify, e.g., communication verbal or coded of pain descriptors, guarding, protective behavior, facial mask of pain, crying, moaning, withdrawal, changes in VS, irritability, restlessness, age-related expression of pain behaviors, facial grimacing, tension or flexion of muscles.) Goal Child will experience less pain by (date time to evaluate). Outcome Criteria V Child verbalizes decreased pain...

Cardiovascular Growth And Development Heart And Blood Vessel Structure

Circulation changes at birth involve the closure of the fetal shunts (foremen ovale at birth, ductus arteriosus by the fourth day after birth, and eventually the ductus venosus). Size of the heart in the infant is large in relation to total body size and occupies more space in the chest surrounded by the lungs. The heart lies at a transverse angle in infancy and gradually changes to a lower and more oblique angle as the lungs grow until maturity is reached. The weight of the heart doubles by 1...

NOC Child Development

Assess parent(s)' understanding of infant's current behavioral states and cues (specify). Provide parents with information about expected infant development (specify if verbal discussion, written information, or video will be used). Help parents to identify their infant's behavioral states and individual cues. Assist parents to identify when the infant's behavior indicates stress caused by excess environmental stimuli (specify). Encourage parents to decrease stimuli when infant appears...

Treatment For Aplastic Anemia

Anti-Lymphocyte Globulin (ALG) or antithymocyte globulin (ATG) suppresses T-cell-dependent autoimmune responses, (based on theory that aplastic anemia is caused by an autoimmune response). Androgens may be used with ATG, may stimulate erythropoiesis. Immunoglobulin (IV) has been successful in the acquired type of aplastic anemia (of infectious origin). Bone Marrow Transplantation is the treatment of choice for severe aplastic anemia. It is the only mode of treatment which may result in a cure...

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...

NIC Surveillance

Provides information indicating infection of wound or skin graft area. Protects child from exposure to infectious organisms. Destroys infectious agents and protects wound from infection. Protects wound from pathogens and reduces risk of infection. Provides method of controlling exposure to infectious agents. Provides information about process of healing and changes to note that should be reported. Prevents transmission of infectious agents to the child. medication regimen to prevent or treat...

NOC Cognitive Orientation

Conditions or infection, cognitive functioning. Assess for increased ICP and effects on orientation mentation, intellectual function, motor function. including PERL, orientation, grip and grasp and pain response, presence of irritability, confusion, memory loss include cranial nerve function if indicated. Elevate head of bed 30 degrees and maintain proper head and neck Provides information about increased ICP which results from brain edema, shift or distortion and brain hypoxia. Provides data...

Appendix Abbreviations

Fl increase 0 decrease leads to > greater than < less than degree ABO refers to the blood types A, B, or O ADHD attention deficit hyperactivity disorder AFDC Aid to Families with Dependent Children AIDS acquired immunodeficiency syndrome ALT alanine aminotransferase (also SGPT) APTT activated partial thromboplastin time ARDS adult respiratory distress syndrome AROM artificial rupture of membranes AST aspartate aminotransferase (also SGOT) BRP bathroom privileges BUN blood urea nitrogen C...

Bronchopulmonary Dysplasia Introduction

Bronchopulmonary dysplasia (BPD) is a chronic lung condition most common in infants that were preterm or small for gestational age (SGA) at birth. It is characterized by varying degrees of lung damage past the age of 1 month. BPD is caused by the use of assistive ventilation with the administration of high concentrations of oxygen to treat respiratory distress syndrome (RDS) or other serious disorders of the neonate. The lung and airway damage affects pulmonary function which leads to oxygen...

Evaluation

(Has goal been met Not met Partially met ) (Does client parent deny nausea and vomiting What is intake in time frame criteria Is skin turgor elastic What is capillary refill time ) (Revisions to care plan D C care plan Continue care plan ) (Revisions to care plan D C care plan Continue care plan ) 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...

Flow Chart For Intussusception

Promotes awareness of signs and symptoms to report to treat complication of wound infection. Indicates gastrointestinal bleeding and possible recurrence or chronicity of condition. Provides information regarding care to expect during hospitalization. Prevents vomiting or abdominal distention until condition resolved. Allows condition and or wound to heal and resolve itself without complications. Provides parents with baseline expected with successful resolution of problem. COPYRIGHT 2005 by...

Genitourinary Growth And Development Organ Structure

Infant kidney size is, proportionately, three times larger than adult size The number of nephrons increase until 1 year of age with continued maturation of the nephrons throughout development of the young child. Tubules and glomeruli continue to form and enlarge after birth tubular length is highly variable but glomeruli size is less variable tubular length increases until 3 months of age. The loop of Henle is short in the infant which affects ability to reabsorb water and sodium causing urine...

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...

Outcome Criteria

V Pain rating is decreased to (specify level and pain scale used). Immobilize joints and apply elastic bandages to the affected joint if prescribed elevate affected extremity joint avoid heat application. that may prolong bleeding time ice packs promote vasoconstriction to active bleeding sites, but must be used cautiously to prevent skin damage in young children. Administer analgesics for pain (specify as ordered). Provide bed cradle over painful joints and or other sites of bleeding. affected...

Leggcalveperthes Disease Introduction

Legg-Calve-Perthes disease (osteochondritis deformans), is a disease of the femoral head occurring in children between 3 to 12 years of age. Its cause is unknown but the disease is characterized by a necrosis of the femoral head which results from an impaired circulation of the femoral epiphysis extending to the acetabulum. Joint dysfunction with hip pain or ache and a limp that is continuous or intermittent are common signs and symptoms of the condition. Early treatment to maintain the femoral...

NOC Pain Level

Assess for location, severity, and duration of pain (specify frequency). Administer analgesics as ordered (specify) administer intermittently over 24-hour period before pain becomes severe rather than wait for request or complaint from child. Provide rest periods, refrain from disturbing child unless necessary. Apply dry heat to area and note response of pain decrease. handle painful areas gently, and support with pillows. Inform parents and child of cause of pain, methods to control it. Teach...

NIC Teaching Disease Process

Promotes plan of instruction that is realistic and prevents repetition of information. Ensures understanding based on readiness and ability to learn visual aids reinforce learning. Provides information about drug therapy, which is the most important treatment for the cure of pneumonia, and about prevention of lung complications resulting from the disease bacterial pneumonia is treated with antibiotic therapy. Promotes proper diet, which enhances health status, and adequate fluid intake, which...

Clinical Pathways A Method Of Achieving Outcomes Across The Continuum Of Care

Health care consumers expect affordable care and optimal outcomes. Third-party providers scrutinize client outcomes to validate the need for expensive health care services. Health care organizations report outcomes to state, federal, and independent agencies to verify practice standards and attract consumers and providers. The demand for the most effective and cost-efficient manner of restoring clients to health has led to collaborative responsibility for client care demonstrated by the...

Conceptual Approach

The nursing process serves as a learning tool for readers and as a practice and documentation format for clinicians. Based on a thorough assessment, the nurse formulates a specific care plan for each individual client. The care plans in this book are provided to facilitate that process for readers and practitioners. To that end, each care plan solicits specific client data and prompts the nurse to individualize the interventions, consider cultural relevance, and evaluate the client's individual...

Nursing Diagnoses Hyperthermia

Defining Characteristics (Specify increase in body temperature above normal range, flushed skin, warm to touch, increased respiratory rate, tachycardia, seizures convulsions.) Defining Characteristics (Specify increase in body temperature above normal range, flushed, dry skin, warm to touch, increased respirations, pulse, oliguria, poor skin turgor, sunken eyeballs.) Goal Child's temperature will be decreased by (date and time to evaluate). Outcome Criteria V Return of body temperature to...

Gastrointestinal Growth And Development

Tooth eruption in infancy at 6 to 8 months with the primary set of teeth completed by approximately 2 years of age. Striated muscles in the throat develop by 6 weeks of age and cerebral connections are developed at 6 months of age to assist in swallowing, which is a reflex activity up to 3 months of age and is stimulated by the flow of milk into the mouth. A coordinated muscular action of swallowing and sucking is necessary. Sucking pads present in cheeks to assist sucking and remain until...

NOC Tissue Integrity Skin and Mucous Membrane

Assess mouth daily for oral ulcers, To effectively treat oral ulcers pain, ability to ingest foods and to promote healing to provide meticulous oral hygiene, to prevent bacterial and Candida prevent oral breakdown and to infections to prevent trauma promote healing (start as soon as a to oral mucosa. drug is used that causes oral ulcers) use a soft sponge toothbrush or toothette, administer frequent mouth rinses, at least every 4 hours and after meals mouth rinses commonly used include Peridex,...

Respiratory System Basic Care Plan Introduction

The respiratory tract is a common site of major and minor disorders in infants and children, and any alteration in respiratory structure or function has a profound effect on the ability to supply the body with oxygen and remove carbon dioxide. A constant supply of oxygen is necessary to sustain organ function and survival, and any decrease in or cessation, obstruction, and infection, can compromise airway patency and pattern. This in turn changes the respiratory rate and efficiency. This...

Compromised Family Coping

Related to (Specify inadequate or incorrect information or understanding, prolonged disease or disability progression that exhausts the physical and emotional supportive capacity of caretakers.) Defining Characteristics (Specify expression and or confirmation of concern and inadequate knowledge about long-term care needs, problems and complications, anxiety and guilt, overprotection of child.) Goal Family will cope effectively with child's illness by (date and time to evaluate).

Pyloric Stenosis Introduction

Pyloric stenosis is a hypertrophic disorder of the circular muscle of the pylorus in which the pylorus is greatly enlarged and hyperplasic and causes progressive narrowing of the canal between the stomach and duodenum. As the canal becomes obstructed over time, associated inflammation and edema result in complete obstruction. The enlarged pylorus muscle may be felt as an olive-like mass in the upper abdomen. The infant appears very hungry but exhibits projectile vomiting soon after eating and...

Critical Thinking The Nursing Process And Care Plan Development

Critical thinking and decision-making skills are used to identify nursing diagnoses. Critical thinking entails purposeful, goal-directed thinking and analysis of information. The nurse uses critical thinking to make clinical judgments based on evidence. The nurse synthesizes the information collected in the assessment and then makes judgments about how to put the information together to form nursing diagnoses. The format of this book encourages the nurse to review the client history and obtain...

NOC Family Functioning

Assess family ability to cope with ill child, strain on family relationships, developmental level of family, response of siblings, knowledge of health practices, family rule behavior and attitude toward long-term care, economic pressures and resources to care for long-term illness. Assist individual family members to identify stressors and behaviors and to define them in positive terms. Assist family members in expressing problems and exploring solutions, responsibilities. Assist in...

NOC Thermoregulation

Assess temperature (specify route and frequency). Administer antipyretic medications as ordered (specify drug, dose, route, and times) and reassess temperature (state when). Remove any extra clothing or covers the child may have on after the antipyretic has taken effect. Encourage fluids (specify if IV running or PO amounts at least 30 cc hr) that child likes (specify). Teach parents how to take the child's temperature (specify). Teach parents about possible side effects of antipyretic...

Anemia Introduction

Anemia is the most common group of hematologic disorders of infancy and childhood. The term anemia refers to a reduction in either the total number of circulating red blood cells (RBC) or a decrease in the concentration of hemoglobin (Hgb). The etiology of anemia is divided into 3 categories 1) excessive blood loss (acute or chronic hemorrhage), 2) increased destruction of RBCs (or hemolysis), or 3) impaired or decreased rate of production (or bone marrow failure). The following three types of...

NOC Energy Conservation

Assess intolerance to activity and manifestations. Maintain bed rest while illness is in acute stage but allow for quiet play and progress as condition allows. Provide access to needed articles within reach, aids to assist in performing ADL. participation as tolerated on a daily basis (specify). Help parents devise a rest and activity schedule which can be adjusted to child's tolerance and allow child to regular activity at own pace (specify). Provides information about extent of fatigue....

Interrupted Family Processes

Related to Situational crisis of long-term condition of child. 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 condition and disabilities of child in a constructive manner, excessive involvement with child by family members, guilt expressed by family members, lack of support from family and friends, irritability and impatience as a...

Medical Care Diagnostic Evaluation

Diagnosis Is Dependent Upon age-related symptoms of UTI an accurate and thorough history of UTI symptoms, patterns of voiding, health practices at home, recurrent treatment of UTI, physical growth and examination, and urine culture lab results. Urine Culture and Sensitivity the gold standard for the diagnosis of UTI, to determine the presence of bacteria in the urine and the drugs to which they are sensitive. UTI will have > 100,000 colony formation units ml (CFU ml) in the first urine...

Interpersonal Development Sullivan

Infant (0 to 1 year) Receive gratification and comfort from loving, tender care develops trust and ability to count on others. Childhood (2 to 5 years) Engage in peer, family, neighborhood activities need adult participation learn to delay gratification and accept interference with wishes gradually seek attention and approval from peers. Juvenile (5 to 12 years) Engage in socialization, competition, cooperation, and compromise develop shared interests and genuine friendships with peers of same...

Risk For Trauma

Related to Developmental age, deficient knowledge and cognitive immaturity predisposing the child to safety hazards in the environment. Defining Characteristics Developmental age, developmental delays, disturbances in gait, vision, hearing, perceptual or cognitive functioning (specify). Goal Child will not experience any trauma by (date time to evaluate). Outcome Criteria V Child engages in appropriate play (specify) without injury. V Parents verbalize safety considerations related to toys...

Itp Introduction

Idiopathic thrombocytopenic purpura (ITP) is an acquired hemorrhagic blood disorder. It is characterized by excessive destruction of platelets (thrombocytopenia) and purpura (a discoloration caused by petechiae beneath the skin). Etiology is unknown but it is believed to be an autoimmune response to disease-related antigens. ITP is classified into two forms 1) acute form, which arises usually after an upper respiratory infection, measles, mumps, or chickenpox and 2) chronic form, which is...

Talipes Introduction

Talipes (club foot) is a congenital disorder of the foot usually with ankle involvement characterized by a twisting out of a normal position that is unable to be manipulated into a different position. The deformity is typed and named according to the position of the foot and includes talipes varus (foot inversion), talipes valgus (foot eversion), talipes equinus (plantar flexion), and talipes calcaneus (dorsiflexion). Most are a combination of these with the most common deformity known as...

Growth And Developmental Changes

Glomerular filtration and absorption values are reached between 1 to 2 years of age. The kidneys' ability to concentrate urine increases at 3 months of age with urea synthesis and excretion reaching adult levels by this time by age 2, urine is concentrated at the adult level. Excretion of water and hydrogen ion is reduced during infancy and excretion of sodium is also reduced during the first month of life with an inefficient reabsorption of sodium. The volume of urinary output varies with age...

NOC Abuse Protection

Assess for bleeding from gums, hematemesis, hematuria, hemathrosis, hematomas, epistaxis, or evidence of easy bruising, petechial rash. Avoid trauma to tissues by avoiding use of hard toothbrush or dental floss, taking rectal temperatures, performing unnecessary invasive procedures, and if administering an IM injection, applying pressure for 5 minutes to site. Administer medications (specify) as ordered. Administer packed RBCs as ordered and monitor for responses, expected and adverse...

Endocrine Growth And Development Introduction

The endocrine system includes the cells of certain glands that produce hormones the organ or tissue sites that receive the hormone and the transport system of the blood, lymph, and extracellular fluids that move the hormones from the point of origin to the point of utilization. Hormones may regulate general cell physiologic activities or may affect specific cells of the body. Glands included in this system are the pituitary, thyroid, parathyroid, adrenal, isles of Langerhans, ovaries, and...

Risk For Injury

Related to Tracheostomy complications. Defining Characteristics (Specify damage to tracheal mucosa by inappropriate suctioning, excessive movement or dislodgement of tube, potential for choking or aspiration. Provides fluids and nutrients of a consistency that is best managed and swallowed to prevent choking. Promotes flow of fluids and foods by gravity. airway to prevent aspiration suctioning after feedings may cause nausea or vomiting. Promotes nutrition requirements that are easier to...

Sexually Transmitted Diseases Introduction

Sexually transmitted diseases (STD) are a diverse group of viral, bacterial, protozoal, and ectoparasitic infections that have a common route of transmission through sexual intercourse. Infectious organisms associated with STDs include Chlamydia trachomatis Neisseria gonorrhoeae bacterial vaginosis, vulvovaginal candidiasis, trichomoniasis syphilis herpes simplex papillomavirus (genital warts) genital herpes and HIV. Infection by each of the above organisms has its own pattern of clinical...

NIC Anxiety Reduction

Uncertainty about treatment and recovery, guilt for presence of illness, possible loss of parental role, feelings and secure information to reduce anxiety. participation in decreasing anxiety. environment. Promotes trust and reduces anxiety. Relieves anxiety caused by fear of the unknown. Reduces anxiety for child by allowing presence and involvement in care, and familiar routines and persons. Promotes trust and comfort and reduces anxiety when cared for by familiar persons. Promotes...

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...

Diagnostic Evaluation for Non Hodgkins Disease

Laboratory Studies CBC with differential, liver and renal function studies, electrolyte, calcium, phosphorus, magnesium, lactate dehydrogenase (LDH), uric acid, EBV titers and urinalysis. Evaluation Includes bone marrow aspiration, lumbar puncture, lymph node biopsy, radiographic studies, CT scans of the lungs and gastrointestinal tract. Supportive Therapies for Both Types are similar to the care discussed in the leukemia child. Treatment for Hodgkin's Disease radiation and chemotherapy....

NIC Teaching Infant Care

Distention, possible flow of liquid into nose or aspirated into lungs causing pneumonia or otitis media or upper respiratory infections. Prolonged feedings may deplete an infant's energy and cause fatigue. Promotes the alignment of maxilla and more normal speech sounds and prevents food from entering nasal cavity. Prevents infection or skin breakdown with cleft lip or palate. Prepares the child to treatments that will be done postoperatively. correction of defect(s) and what to expect during...

Child Abuse Introduction

The term child abuse is used to describe any neglect or mistreatment of infants or children including infliction of emotional pain, physical injury, or sexual exploitation. Neglect or abuse is most often inflicted by the child's biologic parents. Others who have been implicated include foster parents, babysitters, boyfriends, friends, and daycare workers. Nurses are legally and morally responsible to identify children who may be maltreated and to report findings to protect the child from...

Tracheostomy Introduction

The surgical creation of an opening in the trachea between the second and fourth rings is known as a tracheostomy. In children, it may be done to provide an airway to by-pass an acute upper airway obstruction (subglottic stenosis, vocal cord paralysis, epiglottitis, croup) or for long-term mechanical ventilation administration. A plastic tube that softens at body temperature, usually without an inner cannula, is inserted in place and anchored with long sutures taped to the chest during surgery....

Hemophilia Introduction

Hemophilia, an X-linked disorder, is a congenital hereditary bleeding disorder caused by an abnormal gene that produces a defective clotting factor protein with little or no clotting ability. The two most common forms of this disorder are 1) factor VIII deficiency (hemophilia A, or classic hemophilia) and 2) factor IX deficiency (hemophilia B, or Christmas disease). Because both of these disorders are X-linked, the female is the carrier and the disorder is manifested only in males. Hemophilia...

Burns Introduction

Burns are injuries to the skin and underlying tissues caused by flames, electricity, contact with hot articles or water, or radiation therapy. Burns affect children of all ages. They are classified according to severity, source, and extent of surface involved. Most burn injuries occur in children under 5 years of age. Severe burns affect all systems with local responses that include edema, circulatory stasis, and fluid loss. Systemic responses include circulation alteration, anemia, fluid loss,...

Brain Tumor Introduction

A brain tumor is a solid tumor that may be benign, malignant, or a metastatic growth from a tumor in another part of the body. Most central nervous system tumors occur in the cerebellum or brain stem and cause increased intracranial pressure and the symptoms associated with it. Other tumors occur in the cerebrum. A malignant brain tumor is the second most common type of cancer in children and has a poor prognosis as the tumor usually enlarges and becomes advanced before signs and symptoms...

NOC Family Coping

Assess family coping methods used and their effectiveness family ability to cope with child that needs long-term care and guidance stress on family relationships developmental level of family perception of crisis situation by family, response of siblings. Encourage family members to express problem areas and explore solutions together. Assist family members to identify 3 healthy coping mechanisms they can use. Assist family to establish short- and long-term goals for child and importance of...

Tuberculosis Introduction

Tuberculosis (TB) in children is usually contracted from an infected adult by droplets expelled from the respiratory tract and dispersed into the air. Although the incidence and death rate from TB are greater in other parts of the world, there has been an increase of cases in the United States. Rates are high among migrant workers, the homeless, and those who are HIV-positive. Most cases are managed at home with drug therapy. Only patients with more serious forms of the disease or who need...

NIC Health Education

Shows respect for the parents and opens communication. Provides baseline information about current knowledge. auditory and visual means and assesses understanding. Provides information about health promotion. Empower parents to make good parenting decisions for their child to help prevent OM. Positive reinforcement supports decision to improve lifestyle. gaining additional knowledge and skills.

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...

Breathing Pattern And Ventilatory Function

Respiratory rate (ratio to pulse is 1 4) Infant 30 to 60 minute Rate decreases as metabolic needs decrease. Respiratory depth (chest expansion) Infant 2 to 4 inches Toddler 4 to 6 inches Preschool 6 to 8 inches School age 9 to 10 inches Infant obligate nasal and diaphragmatic breathing during first year of life School age changes gradually from infancy through childhood to a more thoracic breathing for girls and a more abdominal breathing for boys volume of inspired air increases as lungs grow...