NURSING CARE PLAN FOR NITUMUSIINA BILLY ADMITTED WITH ACUTE OTITIS MEDIA AND TONSILLITIS

Assessment Diagnosis Planning Intervention Rationale Evaluation

Ineffective airway Expected outcome Goal Monitoring respiratory status; Respiration rate35x/
April 23, 2016 clearance related to rate, depth minute. Difficulty in April 23,
2:00pm retained secret and respiration because of 2016
edema of nasal Demonstrate The patient Monitoring vital signs hourly nasal congestion with 5:00pm
Subjective Data mucous, evidenced adequate will be able clear discharge. Client
Clients by clients mother air exchange, as to Evaluating amount and type of has runny nose Goal met
mother said that he said that he had evidence by: demonstrate secretions being produce. child no
has been irritable runny nose and a. Use of correct adequate RR: longer
and feverish since cough two days, breathing/coughin gas Assessing care-giver knowledge 35breaths/minute,pulse:1 experiencing
the previous night. nasal congestion g technique exchange of contributing causes, treatment 00beats/minute congestion,
Objective Data with clear b. Productive within three plan, specific medication and temperature: 38.80c and can
Temperature discharge, client cough hours. therapeutic procedures perform
0
of 38.8 c cant perform c. Clients and care Clear discharge from coughing
effective cough, giver know and Maintaining adequate fluid nasal. Client cannot expel
Tympanic difficulty understand how to intake especially warm fluid. the secretion by coughing
membranes red and vocalizing help client to it up
bulging bilaterally maintain patent Administering prescribed
airway expectorant, de-congestant Clients parents said that
Pharynx slightly or anti biotics they really concern about
red without client condition and dont
exudates know about the
Lab test WBC : medication
18.010/\9/L
Assessment Diagnosis Planning Intervention Rationale Evaluation

April 23, 2016 Acute pain related Expected outcome Goal Assessing possible From physical
2:15pm to increasing of pathophysiological/psychologica examination revealed 4:46pm
tension in middle Demonstrate a Patient will l causes of pain(e.g., tympanic membrane red
Subjective: ear secondary to decrease in be free of inflammation, trauma, infection and bulging bilaterally. Goal met
infection process symptoms/complai pain and be process) Client diagnosed bilateral child free
Clients signed by clients nts as noted in able to sleep 3.Observingnonverbal cues(e.g., otitis media by from pain
mother said that mother said that defining within 2 how client walks, holds body, pediatrician and is sound
Billy Billy has been characteristics. hours guarding behaviors, grimacing Client seems irritable, asleep
has been irritable irritable and Demonstrate facial, narrowed focus; crying, pulling at ears, and
and since last night feverish since last of relaxation lethargy in infant) crying.
night, clients attitude. Clients parents can
Objective mother said that his b. Client or care- Monitor vital signs during mention some kind of
Patient seems appetite has giver under-stand episodes of pain cues of pain and the way
irritable, crying, decrease, client and demonstrate to manage comfort for
pulling at ears seems irritable, the way to reduce Assessing possible client to reduce pain
Tympanic pulling at ears, panic. pathophysiological/psychologica
membranes red and tympanic Follow prescribed l causes of pain(e.g., Clients parents
bulging bilaterally membranes red and pharmacological inflammation, trauma, infection understand and know
bulging bilaterally regimen process) how to helps their child
to demonstrate the way to
Teaching caregiver to note the maintain same pressure
cues of pain and to manage in ear.
comfort for client

Teaching client or caregiver to

help client demonstrate way to
maintain same pressure in
ear (e.g., promote swallowing
or yawning)
Assessment Diagnosis Planning Intervention Rationale Evaluation
April 23, 2016 Expected outcome Goal Temperature 38.80c
2:20pm Hyperthermia Maintain core Patients Monitoring core temperature by April 23,
related to Increase temperature within temperature appropriate route 2016
Subjective metabolism normal range will reduce 4:40pm
secondary to Demonstrate by at least Administering antipyretic
Patients mother disease/infection behaviors to 20c within medications.
said that he had process signed by monitor and one hour
been feverish since Clients mother promote normo- Discussing importance Goal met
the previous night said that he has thermiac. of adequate fluid intake at all Clients parents express childs
been irritable and Client and care- times and ways to improve the understanding temperature
Objective feverish since last giver understand hydration status when ill of importance reduce to
night, temperature and able to or when under stress (e.g., of adequate fluid intake 36.30c
Temperature of of 38.80c mention ways to exercise, hot environment).
38.80c promote normo- Removing heavy clothings
thermia Performing tepid sponging
Skin feels hot
April 24, 2016 Infection related to The childs The patient Encourage breast feeding Breast feeding affords
2:30 Am presence of temperature is will be free natural immunity to April 24,
pathogens normal, symptoms from pain infectious agents 2016
Subjective evidenced by raised have disappeared within 24 Administer antibiotics as 2:20pm
Patients mother erythrocyte count and tympanic hours prescribed Taking antibiotics as
said he had been and tympanic membranes show prescribed minimizes the Goal
pulling at ears and membranes red, no signs of Ensure proper ear hygiene chances of overgrowth of achieved ,
crying, feeling bulging bilaterally infection pathogens. childs
feverish and temperature
irritable normal and
tympanic
Objective membrane
Tympanic shows no
membranes red, signs of
bulging bilaterally infection

Temperature
38.80c
Erythrocytes count
of
5.2810/\12/L

Altered nutrition: Client/caregiver ve Patient will Assess client/care- Identifies teaching needs April 23,
April 24, 2016 Risk for less than rbalizing be able to giver knowledge of nutritional and/or helps guide choice 2016
8:00 Am body requirement understanding how take light needs and ways client is meeting of intervention. 8:50am
related to decreased to keep adequate food and these needs. Increase appetite can
appetite and the nutrition intake breast feed increase the nutrition
Subjective increased for client efficiently Teach client/care-giver way to intake.
metabolism Client finishing all within 48 in-crease appetite: Goal met
Clients secondary to of his meal hours To promote sense of partially
mother said that his disease process. Present weight in Determine when client control and give client Child is
appetite and breast control prefers/tolerates largest meal of opportunity to eat when able to
feeding have the day. feeling more rested, less breast feed
decrease since the Maintain flexibility in timing pain or nausea Continuing
fever started. of food intake intervention
Reduce feeling for client
of fullness that can homecare
accompany larger meals, and
and to improve modification
Encourage variety in food chances of increasing the to plan care
Objective: choice, varying textures and amount of nutrients taken
taste sensations(e.g. sweet, salty, over 24-hour period.
Pharynx slightly Enhance food satisfaction
red without and stimulate appetite.
exudates

Disturbed sensory Demonstrate the The patient Assessing possible

April 24 , 2016 perception related ability to hear will be able pathophysiological/psychologica
8:05 Am to obstruction, well. to gain his l causes of pain(e.g.,
 infection of the normal inflammation, trauma, infection April 25,
Subjective middle ear or Prevent infection auditory process) 2016
Patients mother auditory nerve from ascending to abilities 8:50pm
said he had been damage evidenced the lower within 48 Apply a warm pad Head increases blood
pulling at ears and by patient pulling at respiratory organs hours supply and reduces
crying. ears discomfort
Goal
Objective Administer antibiotics such To counteract the achieved
tympanic slightly gentamycin ear drops infection.
red without Mother
exudates advised to
maintain ear
hygiene and
to look out
for any
discomfort
April 25 , 2016
8:05 Am

Child greatly improved, all goals of care achieved, child ready for discharge
Discharged on 25th April 2016 at 11:06 am
Treatment on discharge
Syrup paracetamol 250mg 8hourly x 2/7
Syrup Amoxyl 125 mg 8 hourly x 5/7
Advice on discharge
Take treatment as requires
Monitor any warning signs
Ensure enough fluid intake