NURSING

CARE PLAN
SN Nursing Nursing goal Nursing intervention Rationale Evaluation
diagnosis

1. Imbalanced The client will - Record the number -Variations help identify fluctuating My goal was met the
Nutrition:Less maintain and quality of faecal intravascular volumes or changes in risk for fluid deficit was
than Body adequate vital signs associated with immune minimized.
requirements infantile body response to inflammation
-Monitor skin turgor
related to fluids -indicators of adequacy of peripheral
inadequate intake circulation and cellular hydration
and                 -Monitor intake output -Monitor intake and output (I &O);note
diarrhoea urine color and concerntration and
-Give water between specific gravity
breastfeeding or giving -Indicators of return of peristalsis and
a bottle readiness to begin oral intake

-Reduces risk of gastric irritation and

vomiting to minimize fluid loss

2.  Impaired skin The integrity -Useful in monitoring effectiveness of My goal was partially
integrity related to of the baby medication,progression of met. The patient was
hyperbilirubinemia skin can be - Assess skin color healing.Changes in characteristics of quiet relieved by the
and diarrhoea maintained every 8 hours pain may indicate developing therapy but not
abcess /peritonitis,requiring prompt controlled.
medical evaluation and intervention.
-Monitor direct and
-Being informed about progress of
indirect bilirubin
 situation provides emotional support,
-Change position every helping to decrease anxiety
2 hours -Relief of pain facilitates cooperation
-Massage the area that with other therapeutic interventions,
stands out -Refocuses attention, promotes
relaxation, and may enhance coping
abilities. 
-Keep your skin clean -Decreases discomfort of early
and moisture intestinal peristalsis and gastric
irritation/vomiting.

3. Anxiety related to -to relieve -examine the level of Understanding promotes cooperation My goal was met the
change in health anxiety anxiety with therapeutic regimen, enhancing patient party was less
status(patient’s healing and recovery process anxious and well
mother) oriented about his
-Give information about
disease condition.
the disease process
and actions -to gain trust from the patient party
-reassure the patient
party
-Enhance the patient
general activity

4. Fluid volume maintain fluid -document and - Useful in My goal was fully met,
deficit r/t poor and monitor :intake and assess for signs of blood transfusion done,
 absorption electrolyte output,  specific gravity, dehydration, assess for fluid overload, haemodynamically
balance daily weights, daily stabilized.
abdominal girth -regular vital sign helps to rule out any
measurements, deviation normal body functions as
well as presence of infection in body
-check vitals, monitor -to maintain haeomostatic equilibrium
for signs of tachycardia - to assess the proper liver function
or new murmurs, and kidney function

 -blood transfusion -to assess the peripheral circulation

-Check laboratory
studies for electrolyte
imbalances,

-Capillary refill less than

3 seconds and urine
output.
5. Potential for Infant/ child -Monitor growth curve- Chart above information, be able to My goal was partially
altered growth- grow monitor weight on identify and   report abnormalities and met. The patient party
due to liver following regular basis. reassess was well instructed for
disease growth curve the continuous growth
-assess range of motion, gross and
while monitoring.
-Assure that ADEK fine motor skills
maintaining
appropriate vitamins taken on
nutritional regular basis, monitor
lab values.
 status
-Instruct regarding
methods to increase
calories: medium chain
triglyceride formula,
additional formula
supplementation.
6. Knowledge deficit Parents -Teach parents about Proper knowledge about the disease My goal was met. The
R/T Homecare understand medications including helps to promote cooperation with parents were well
Instructions home care purpose, dose, therapeutic regimen, enhancing conscious about the
instructions.  patient and caring.
administration, side healing and recovery process as well
effects and signs and as coping abilities.
symptoms to report. -regular follow up helps for regular
monitoring of the child’s health status.
-Teach parents
importance of
compliance relating to
testing, medications
and follow-up visits.
Teach parents to
identify, verbalize and
report changes in
child’s health status.

8. Health Family/ -Review with parents Early instruction about the My goal was met. The
Maintenance Parents the signs and complications due to   altered body patient party was well
Altered ,need for familiar with symptoms of worsening function helps in early identification conscious about the
family to monitor symptoms of liver function including: and treatment if present child and no any
for symptoms of complication shows
worsening change in stool color,
increased liver up. Though,blood
liver function. ascites, peripheral
dysfunction transfusion was done.
edema,
hepato/spleenomegaly,
anorexia, urine color,
lethargy, jaundice, -early management help to gain good
bleeding, and pruritus. prognosis if any complication prevails.

-Educate regarding -the early identification helps in

complications of end effective management.
stage liver disease.

-Attempt to identify of
signs and symptoms of
bleeding with treatment
of vitamin K or perhaps
even a transfusion
APPLICATION OF NURSING THEORY
 
                       By applying nursing theory of  Faye Glenn Abdellah's Theory,
holistic care was given to my patient from the day of my visit.

"Nursing is based on an art and science that mould the attitudes, intellectual
competencies, and technical skills of the individual nurse into the desire and
ability to help people , sick or well, cope with their health needs." -
Abdellah                      

“Although Abdellah spoke of the patient-centered approaches, she wrote of nurses

identifying and solving specific problems. This identification and classification of problems
was called the typology of 21 nursing problems. Abdellah’s typology was divided into three
areas:
(1) the physical, sociological, and emotional needs of the patient;
 (2) the types of interpersonal relationships between the nurse and the patient; and
(3) the common elements of patient care.

Adbellah and her colleagues thought the typology would provide a method to evaluate a
student’s experiences and also a method to evaluate a nurse’s competency based on
outcome measures.”

(Tomey & Alligood, Nursing theorists and their work 4th ed., p. 115).

Abdellah’s Typology of 21 Nursing Problems are as follows:

1. To promote good hygiene and physical comfort

2. To promote optimal activity, exercise, rest, and sleep
3. To promote safety through prevention of accidents, injury, or other trauma and through the
prevention of the spread of infection
4. To maintain good body mechanics and prevent and correct deformities
5. To facilitate the maintenance of a supply of oxygen to all body cells
6. To facilitate the maintenance of nutrition of all body cells
7. To facilitate the maintenance of elimination
8. To facilitate the maintenance of fluid and electrolyte balance
9. To recognize the physiologic responses of the body to disease conditions
10. To facilitate the maintenance of regulatory mechanisms and functions
11. To facilitate the maintenance of sensory function
12. To identify and accept positive and negative expressions, feelings, and reactions
13. To identify and accept the interrelatedness of emotions and organic illness
14. To facilitate the maintenance of effective verbal and nonverbal communication
15. To promote the development of productive interpersonal relationships
16. To facilitate progress toward achievement of personal spiritual goals
17. To create and maintain a therapeutic environment
18. To facilitate awareness of self as an individual with varying physical, emotional, and
developmental needs
19. To accept the optimum possible goals in light of physical and emotional limitations
20. To use community resources as an aid in resolving problems arising from illness
21. To understand the role of social problems as influencing factors in the cause of illness

HEALTH EDUCATION TO THE CLIENT AND FAMILY

REGARDING HEALTH MAINTAINANCE
             
               Health teaching plays an important role to prevent disease, promote health
as well as to cure diseases more rapidly without any complications. One of the most
important roles of nurse is to provide health education. So, I provided health teaching
to family as well as patient objectives of health education are as follows:
-To promote health
-To motivate for early diagnosis and treatment
-To help limitation of disability
-To help in rehabilitation.

         Keeping these objectives in mind, I gave informal teaching and information to
patient and family.

-Nutrition: The importance of nutritious food and balanced diet. He was advised to
take plenty of fluids and soft hygienic foods.

-Infection prevention: I gave teaching on importance of personal hygiene and the role
of hygiene in infection control

-Rest and exercise: Adequate sleep is necessary for the patient.

- breast feeding
-Supplementary foods
 -immunization
-Personal hygiene
-About disease
-Medications
-Follow up.

                                  
CONCLUSION
         Case study is one of the most important parts of nursing practice. It is the best
method of learning case study concerned with the individualized care which helps to
provide holistic nursing care including physiological, psychological, social and
cultural traditional beliefs.
         According to our B.N. 1st year curriculum, I had taken a case of Jaundice,
named Shishir Kuwar for case study. During this period of case study, at first, I had
collected relevant health history from the patient as well as his family members.
Then I had done complete physical examination of my patient. I gathered lots of facts
and formulated nursing diagnosis. I applied knowledge from the basic sciences,
nursing theories and other related courses, to plan and implement nursing care. I
had studied the normal developmental task of infant and correlate it with my patient.
He meets these entire normal developmental tasks.
         I had also studied about disease its type, epidemiology, etiological factors,
Pathophysiology, clinical manifestations, diagnostic test, therapeutic and nursing
management including Prognosis, Prevention and Possible Complications.
         I had provided different diversion therapy to the patient for stress
management.           
         Finally patient’s general condition was improved day by day and I am satisfied
from this case study and the goals set were fully met.

References
      1.      AZ of Practical Paediatrics,Baral Manindra.R,HISI Offset
printers1st edition,2007,page 234-238
      2.      Nursing 2012 Drug Handbook,Kluwer Wolters,Lippincott Williams and wikins, 32
edition page 780,1169,273,1466.
      3.      http://www.whereincity.com
      4.      Child health Nursing,uprety kamala,pradipa printing and publishing 1st edition pg no:
200-208
      5.       http://www.medindia.net
      6.       http://www.drugs.com
      7.  Internet: www.google.com.np