SHEENA MARIE M.

TARLE BSN 2-C

NCM 109 – CARE OF MOTHER, CHILD, ADOLESCENT AT RISK OR WITH PROBLEMS
(ACUTE AND CHRONIC)

Given all the diseases from the reports (premidterm) give at least 2 nursing diagnosis with 5
corresponding nursing interventions.
ACUTE NASOPHARYNGITIS
Nursing Diagnosis: Ineffective Airway Clearance related to increased production of
respiratory secretions secondary to acute nasopharyngitis
Nursing Interventions:
1. Monitor respirations and breath sounds, noting rate and sounds
2. Elevate the head of the bed or encourage semi-Fowler's position to promote drainage of
respiratory secretions and improve breathing.
3. Encourage and assist the patient with effective coughing techniques, such as deep
breathing exercises and controlled coughing, to facilitate the clearance of respiratory
secretions.
4. Encourage adequate fluid intake to promote hydration and help thin respiratory
secretions, making them easier to clear.
5. Administer prescribed medications such as expectorants or mucolytics to help liquefy and
facilitate the removal of respiratory secretions.
Nursing Diagnosis: Impaired Gas Exchange related to nasal congestion
Nursing Interventions:
1. Monitor the patient's oxygen saturation levels and respiratory rate, depth, and effort to
assess gas exchange and respiratory status.
2. Encourage and assist the patient with effective coughing techniques and deep breathing
exercises to promote airway clearance and improve ventilation.
3. Assist the patient with proper positioning, such as sitting upright or using pillows to
elevate the head, to optimize respiratory mechanics and facilitate breathing.
4. Administer prescribed medications such as decongestants or expectorants to reduce nasal
congestion and facilitate the removal of respiratory secretions.
5. Educate the patient on the importance of maintaining hydration, adequate rest, and
avoiding irritants such as smoke or pollutants that can exacerbate respiratory symptoms.
TONSILITIS
Nursing Diagnosis: Ineffective Airway Clearance related to swelling of the tonsils
Nursing Interventions:
1. Monitor for signs of respiratory distress, such as stridor, nasal flaring, or use of accessory
muscles.
2. Encourage the patient to maintain an upright position whenever possible to promote
optimal lung expansion and airway clearance.
3. Teach the patient effective coughing and deep breathing techniques to clear respiratory
secretions and improve airway patency.
4. Ensure proper suctioning technique to minimize trauma to the mucosa and avoid
stimulating the gag reflex excessively.
5. Encourage increased fluid intake to maintain adequate hydration and thin respiratory
secretions, making them easier to expectorate.
Nursing Diagnosis: Acute Pain related to inflamed tonsils
Nursing Interventions:
1. Monitor vital signs for any signs of distress or changes indicating worsening pain.
 2. Administer prescribed analgesics as ordered by the physician, ensuring timely
administration to maintain pain control.
3. Encourage the patient to rest in a comfortable position, preferably with the head elevated
to reduce throat discomfort.
4. Encourage adequate hydration by offering small, frequent sips of water or other preferred
fluids to prevent dehydration and soothe the throat.
5. Provide warm saline gargles or throat lozenges to relieve throat irritation and promote
healing.
SINUSITIS
Nursing Diagnosis: Ineffective airway clearance related to retained bronchial secretions
Nursing Interventions:
1. Auscultate lung sounds on anterior and posterior thorax.
2. Position the patient in a semi-fowler’s position.
3. Teach patient to perform proper coughing techniques.
4. Encourage adequate rest.
5. Increase fluid intake.
Nursing Diagnosis: Ineffective Breathing Pattern related to nasal congestion and
inflammation secondary to sinusitis
Nursing Interventions:
1. Assess for signs of respiratory distress such as nasal flaring, use of accessory muscles,
and cyanosis.
2. Encourage the patient to maintain a semi-Fowler's position to optimize lung expansion
and facilitate breathing.
3. Teach and assist the patient with deep breathing exercises to improve lung expansion and
promote ventilation.
4. Promote adequate hydration to help thin respiratory secretions and facilitate their removal
from the airways. Offer fluids frequently and monitor intake/output to ensure hydration
status.
5. Educate the patient on techniques such as pursed-lip breathing and diaphragmatic
breathing to improve respiratory efficiency and reduce respiratory distress.
ASPIRATION
Nursing Diagnosis: Impaired Swallowing related to esophageal stricture or spasm
Nursing Interventions:
1. Inspect oropharyngeal cavity for edema, inflammation, altered integrity of oral mucosa,
adequacy of oral hygiene.
2. Keep patient seated upright or elevate the head of bed.
3. Instruct patient to cough and expectorate when secretion management is of concern.
4. Implement swallowing exercises and techniques
5. Maintain good oral hygiene by assisting with oral care after meals and providing frequent
mouth care to prevent complications such as aspiration pneumonia.
Nursing Diagnosis: Ineffective Airway Clearance related to aspiration risk as evidenced by
productive cough, dyspnea, and presence of abnormal breath sounds
Nursing Interventions:
1. Auscultate lung sounds for adventitious breath sounds such as crackles or wheezes.
2. Position the patient in a semi-Fowler's position to facilitate lung expansion and improve
ventilation.
3. Encourage adequate fluid intake within the patient's prescribed limits to thin respiratory
secretions and promote expectoration.
4. Encourage deep breathing and coughing exercises to improve lung expansion and
promote effective coughing to clear secretions.
 5. Administer bronchodilators or mucolytic agents as prescribed to relieve bronchospasm
and facilitate the expectoration of thick secretions.
INFLUENZA
Nursing Diagnosis: Risk for Fluid Volume Deficit related to fever, decreased oral intake, and
increased insensible fluid loss due to Influenza infection
Nursing Interventions:
1. Monitor vital signs, including blood pressure, heart rate, and temperature, for signs of
dehydration.
2. Assess intake and output, including urine output, vomiting, diarrhea, and insensible fluid
loss
3. Provide oral rehydration solutions or electrolyte replacement drinks if necessary to
replenish lost fluids and electrolytes.
4. Encourage intake of foods and fluids rich in electrolytes, such as bananas, potatoes,
sports drinks (if appropriate), and broth.
5. Implement fall prevention measures, especially for patients who may experience
weakness or dizziness due to dehydration.
Nursing Diagnosis: Risk for Altered Breathing Pattern related to respiratory distress
secondary to Influenza infection.
Nursing Interventions:
1. Assess respiratory rate, depth, and rhythm regularly, noting any signs of dyspnea or
increased work of breathing.
2. Position the patient in a semi-Fowler's position to facilitate optimal lung expansion and
ease breathing efforts.
3. Monitor oxygen saturation continuously and adjust oxygen flow rates as necessary to
achieve target levels.
4. Administer prescribed respiratory treatments, such as nebulized bronchodilators or
mucolytic agents, to relieve bronchospasm and facilitate secretion clearance.
5. Encourage adequate hydration to help thin respiratory secretions and facilitate
expectoration.
PNEUMONIA
Nursing Diagnosis: Ineffective Airway Clearance related to the increased production of
respiratory secretions
Nursing Interventions:
1. Auscultate lung fields, noting areas of decreased of absent airflow and adventitious
breath sounds
2. Encouraged deep breathing exercises.
3. Increase fluid intake, as appropriate
4. Assist patient into moderate high back rest.
5. Administer ordered medications such as mucolytic agents, bronchodilators, expectorants.
Nursing Diagnosis: Acute pain related to localized inflammation and persistent cough
Nursing Interventions:
1. Elevate head of bed, change position frequently
2. Encourage patient to do deep breathing exercises.
3. Demonstrate or help patient learn to perform activity like splinting chest and effective
coughing while in upright position.
4. Administer medications as prescribed such as mucolytics, expectorants
5. Provide supplemental fluids.
ALLERGY
Nursing Diagnosis: Ineffective Airway clearance related to environmental factors
Nursing Interventions:
1. Monitor respiration and breath sounds
2. Elevate head of bed, encourage early ambulation, or change client position every 2 hours.
3. Educate patient and SO about use of nasal sprays
4. Encourage SO in thorough cleaning of the house and precautions in going outside home.
5. Encourage medication compliance.
Nursing Diagnosis: Impaired Skin Integrity related to allergic dermatitis secondary to
exposure to environmental allergens
Nursing Interventions:
1. Conduct a comprehensive assessment of the patient's skin, including location, type, and
severity of lesions, as well as the presence of pruritus and inflammation.
2. Encourage gentle cleansing of the affected area with mild, fragrance-free soap and
lukewarm water to remove allergens and minimize irritation.
3. Instruct the patient to avoid scratching or rubbing the affected area to prevent further
damage to the skin and reduce the risk of infection.
4. Administer prescribed topical corticosteroids or antihistamines to reduce inflammation,
itching, and discomfort.
5. Advise the patient to avoid activities that may exacerbate symptoms, such as prolonged
exposure to hot water, excessive sweating, or contact with known allergens.
ATOPIC DISORDER
Nursing Diagnosis: Impaired Skin Integrity related to atopic disorder (eczema)
Nursing Interventions:
1. Regularly assess the patient's skin integrity, noting any changes in texture, color, and
presence of lesions.
2. Encourage the patient to hydrate their skin regularly using fragrance-free moisturizers or
emollients.
3. Instruct the patient to bathe with lukewarm water using mild, fragrance-free soap and to
avoid scrubbing or rubbing the skin vigorously. Pat the skin dry gently with a soft towel.
4. Teach the patient techniques to minimize scratching, such as using cold compresses,
wearing soft gloves at night, and keeping fingernails short to reduce skin damage from
scratching.
5. Administer prescribed antihistamines or topical corticosteroids to relieve itching and
inflammation as directed by the healthcare provider. Monitor for adverse effects of
medications.
Nursing Diagnosis: Impaired Comfort related to pruritus and inflammation secondary to
atopic disorder (eczema).
Nursing Interventions:
1. Regularly assess the patient's comfort level, paying attention to verbal and non-verbal
cues of discomfort such as scratching, restlessness, and facial expressions indicative of
pain or itchiness.
2. Administer prescribed antihistamines, corticosteroids, or topical calcineurin inhibitors to
alleviate itching and inflammation
3. Apply cool, damp compresses or wet wraps to affected areas to soothe itching and reduce
inflammation. Ensure the compresses are not too cold to avoid discomfort or skin
damage.
4. Teach relaxation techniques such as deep breathing exercises, guided imagery, or
distraction techniques to help the patient cope with discomfort and reduce stress, which
can exacerbate symptoms.
5. Encourage the patient to wear loose-fitting, breathable clothing made from soft fabrics
such as cotton to minimize irritation and promote comfort.
RUBELLA
Nursing Diagnosis: Impaired Comfort related to Rubella infection
Nursing Interventions:
1. Administer prescribed antipyretics, such as acetaminophen, to reduce fever and alleviate
discomfort.
2. Encourage cool baths or showers to help soothe the skin and alleviate discomfort.
3. Encourage increased fluid intake to maintain hydration, especially if the patient has a
fever.
4. Encourage the use of warm compresses or heating pads to alleviate muscle aches and
pains associated with rubella infection.
5. Regularly assess the patient's vital signs and monitor for any signs of complications such
as dehydration or secondary bacterial infections.
Nursing Diagnosis: Risk for Complications related to Rubella infection
Nursing Interventions:
1. Place the patient on droplet precautions to prevent the spread of rubella to others.
2. Monitor the patient's temperature regularly to detect fever.
3. Offer symptomatic relief measures such as acetaminophen for fever and discomfort.
4. Encourage increased fluid intake to prevent dehydration, especially if the patient has a
fever.
5. Ensure adequate rest for the patient to support the body's immune response.
MEASLES
Nursing Diagnosis: Risk for Complications related to Measles Virus Exposure
Nursing Interventions:
1. Implement airborne precautions to prevent the spread of measles virus
2. Assess respiratory status for signs of respiratory distress, such as increased respiratory
rate or difficulty breathing.
3. Encourage adequate fluid intake to prevent dehydration, especially in cases of fever and
increased sweating.
4. Administer antipyretics as prescribed to reduce fever and discomfort.
5. Provide cool, damp cloths or tepid sponge baths to help alleviate fever and relieve skin
irritation from the rash.
Nursing Diagnosis: Impaired Tissue Integrity related to Measles Virus Infection
Nursing Interventions:
1. Apply prescribed topical treatments, such as calamine lotion or antihistamines, to reduce
itching and discomfort.
2. Encouraged patient to avoid scratching the rash to prevent further tissue damage and
infection.
3. Cleanse infected areas with antiseptic solutions as prescribed to prevent the spread of
infection.
4. Provide a well-balanced diet rich in protein, vitamins, and minerals to support immune
function and promote tissue repair.
5. Administer analgesics as prescribed to alleviate pain and discomfort associated with the
rash and secondary skin infections.
CHICKEN POX
Nursing Diagnosis: Risk for Infection related to compromised skin integrity secondary to
chickenpox lesions.
Nursing Interventions:
1. Implement airborne and contact precautions to prevent the spread of the virus.
2. Encourage the patient to perform frequent handwashing with soap and water for at least
20 seconds to reduce the risk of spreading the virus.
 3. Advice the patient to keep the chickenpox lesions clean and dry. Avoid breaking the
blisters to prevent secondary bacterial infection.
4. Administer prescribed analgesics, such as acetaminophen or ibuprofen, to relieve pain
and reduce fever.
5. Encourage the patient to rest in a comfortable position to minimize discomfort and
promote healing
Nursing Diagnosis: Impaired Comfort related to pruritus and discomfort associated with
chickenpox lesions.
Nursing Interventions:
1. Administer prescribed antihistamines or topical corticosteroids to reduce itching and
inflammation.
2. Advice patient to have cool compresses or cool baths to relieve discomfort and reduce
inflammation. Ensure the water is not too cold to avoid shocking the patient's system.
3. Advice patient to wear loose-fitting, cotton clothing to minimize friction and irritation to
the skin.
4. Engage the patient in activities such as reading, listening to music, or watching movies to
divert attention away from discomfort.
5. Encourage adequate fluid intake to prevent dehydration and promote skin hydration.
SMALL POX
Nursing Diagnosis: Risk for Complications related to inflammation secondary to smallpox
infection.
Nursing Interventions:
1. Monitor the patient's vital signs and inflammatory markers such as C-reactive protein
(CRP) and erythrocyte sedimentation rate (ESR) to assess the severity of inflammation
and detect complications early.
2. Apply cold compresses or ice packs to inflamed areas to reduce swelling, pain, and
localized heat associated with inflammation.
3. Elevate affected limbs or body parts to promote venous return and reduce swelling
associated with inflammation.
4. Administer anti-inflammatory medications such as corticosteroids or nonsteroidal anti-
inflammatory drugs (NSAIDs) as prescribed to reduce inflammation and prevent
complications.
5. Cleanse inflamed areas gently with saline solution to remove debris and exudate,
promoting a clean environment for healing.
Nursing Diagnosis: Impaired Tissue Perfusion related to inflammatory response in smallpox
infection.
Nursing Interventions:
1. Monitor the patient's vital signs, peripheral pulses, capillary refill, and skin color and
temperature to assess tissue perfusion adequacy.
2. Position the patient in a comfortable and optimal position to promote adequate blood
flow to tissues.
3. Ensure adequate hydration by encouraging the patient to drink fluids regularly.
4. Cleanse wounds gently with saline solution to remove debris and promote tissue
perfusion. Apply topical antimicrobial agents as prescribed to prevent infection and
facilitate healing of inflamed tissues.
5. Administer vasodilator medications as prescribed to improve peripheral circulation and
enhance tissue perfusion.
RABIES
Nursing Diagnosis: Risk for Injury related to altered mental status and potential for
aggression secondary to rabies infection.
Nursing Interventions:
 1. Continuously monitor the patient's mental status, behavior, and signs of aggression.
2. Assess for any signs of hydrophobia, hyperactivity, hallucinations, or photophobia.
3. Implement strict isolation precautions to prevent transmission of the rabies virus to
others.
4. Administer prescribed medications, such as rabies vaccine and immunoglobulin
5. Provide medications to manage symptoms, such as sedatives or antipsychotics, to control
agitation and aggression.
Nursing Diagnosis: Impaired skin integrity related to disruption of skin surface with
destruction of skin layers
Nursing Interventions:
1. Assess or document size, color, depth of wound, and condition of surrounding skin
2. Thoroughly wash the wound as soon as possible with antibacterial soap for
approximately 5 mins.
3. Apply antiseptic solution in the wound.
4. Keep the skin free from pressure.
5. Implement contact isolation for respiratory secretions, especially saliva in the duration of
the illness.
SCARLET FEVER
Nursing Diagnosis: Impaired Comfort related to Scarlet Fever rash
Nursing Interventions:
1. Administer prescribed antipyretics to reduce fever and discomfort.
2. Avice the patient to keep the skin clean and dry to prevent irritation and secondary
infection.
3. Encourage gentle cleansing of the affected areas with mild soap and water.
4. Apply moisturizing creams or ointments to hydrate the skin and reduce itching.
5. Use distraction techniques such as relaxation techniques, music therapy, or guided
imagery to help the patient cope with discomfort.
Nursing Diagnosis: Risk for Infection Transmission related to scarlet fever
Nursing Interventions:
1. Place the patient on appropriate isolation precautions as per institutional protocols to
prevent the spread of infection.
2. Emphasize the importance of thorough handwashing with soap and water or using
alcohol-based hand sanitizers, especially after coughing, sneezing, or touching surfaces.
3. Ensure thorough cleaning and disinfection of patient care areas, including surfaces,
equipment, and frequently touched objects.
4. Provide education to the patient and family members about scarlet fever transmission and
prevention strategies.
5. Monitor the patient's condition closely for signs of improvement or complications related
to scarlet fever.
DIPHTHERIA
Nursing Diagnosis: Impaired Airway Clearance related to diphtheria infection, as evidenced
by respiratory distress, stridor, and potential airway obstruction.
Nursing Interventions:
1. Auscultate lung sounds for adventitious sounds such as wheezing or stridor.
2. Position the patient in semi-Fowler's position to maximize lung expansion and ease
breathing effort.
3. Encourage oral fluid intake if tolerated to prevent dehydration and maintain mucous
membrane hydration.
4. Adhere strictly to infection control measures to prevent the spread of the diphtheria
infection
 5. Administer diphtheria antitoxin promptly as prescribed to neutralize the circulating toxin
Nursing Diagnosis: Risk for Complications related to diphtheria infection and associated
respiratory compromise
Nursing Interventions:
1. Monitor respiratory status closely, including respiratory rate, effort, and oxygen
saturation levels.
2. Position the patient in a semi-Fowler's position to promote optimal lung expansion and
facilitate breathing.
3. Initiate antibiotic therapy (e.g., penicillin or erythromycin) to eradicate the causative
organism, Corynebacterium diphtheriae, and reduce the risk of systemic complications.
4. Monitor fluid intake and output closely to ensure adequate hydration and prevent
dehydration, especially if the patient has a fever or increased respiratory rate.
5. Adhere strictly to infection control protocols, including droplet precautions, to prevent
the spread of diphtheria
TETANUS
Nursing Diagnosis: Ineffective airway clearance related to accumulation of sputum in the
trachea and respiratory muscle spasm
Nursing Interventions:
1. Position the patient, adjust the position of head extension
2. Auscultate breath sounds
3. Monitor Vital signs
4. Watch out for onset of respiratory failure/apnea
5. Administer secretion-thinning medication (mucolytics) as prescribed
Nursing Diagnosis: Risk for Injury related to muscle spasms and rigidity secondary to
tetanus infection.
Nursing Interventions:
1. Monitor vital signs frequently, especially temperature, as fever can exacerbate muscle
rigidity.
2. Assess for signs and symptoms of tetanus infection such as muscle stiffness, jaw
cramping (lockjaw), and difficulty swallowing or breathing.
3. Teach proper hygiene practices to minimize the risk of infection.
4. Administer prescribed analgesics to alleviate muscle pain and discomfort.
5. Apply warm compresses to affected muscles to help alleviate spasms and increase blood
flow.
LEUKEMIA
Nursing Diagnosis: Risk for Bleeding related to thrombocytopenia secondary to leukemia
and potential side effects of treatment.
Nursing Interventions:
1. Regularly monitor platelet counts and assess for signs of bleeding, such as petechiae,
ecchymosis, or bleeding gums.
2. Implement fall precautions, including keeping the patient's environment free of hazards,
providing nonslip footwear, and assisting with ambulation as needed to prevent falls that
could lead to bleeding injuries.
3. Provide a soft-bristled toothbrush and encourage gentle oral care to prevent gum
bleeding. Instruct the patient to avoid vigorous brushing and use of dental floss.
4. Ensure that anticoagulant medications, if prescribed, are administered at the correct dose
and frequency to prevent excessive bleeding
5. Apply pressure to minor cuts or abrasions for an extended period to promote hemostasis
and prevent excessive bleeding.
Nursing Diagnosis: Impaired Physical Mobility related to weakness, fatigue, and
musculoskeletal complications secondary to leukemia
Nursing Interventions:
1. Conduct a comprehensive assessment of the patient's mobility status, including strength,
balance, coordination, range of motion, and ability to perform activities of daily living
2. Implement safety measures to prevent falls and injuries, including keeping walkways
clear, using non-slip mats, and providing supervision during mobility activities.
3. Encourage gradual progression of mobility activities, starting with simple tasks and
gradually increasing intensity and duration as tolerated to build strength and endurance.
4. Teach energy conservation techniques such as pacing activities, alternating between
periods of activity and rest, and using proper body mechanics to minimize fatigue and
maximize mobility.
5. Address pain and discomfort that may limit mobility through pharmacological and non-
pharmacological interventions, ensuring adequate pain control to optimize participation
in physical activities.
LYMPHOMA
Nursing Diagnosis: Impaired Comfort related to pain and discomfort secondary to
lymphoma.
Nursing Interventions:
1. Conduct thorough pain assessments regularly using pain scales.
2. Administer analgesics as prescribed by the physician.
3. Encourage the patient to take frequent rest periods throughout the day.
4. Assist with positioning to alleviate discomfort, considering the patient's preferences and
mobility limitations.
5. Take appropriate measures to prevent infections, including hand hygiene, isolation
precautions when necessary, and education on infection control practices.
Nursing Diagnosis: Risk for Infection related to compromised immune function secondary
to lymphoma
Nursing Interventions:
1. Monitor white blood cell counts and other relevant laboratory values indicative of
immune function.
2. Assess for signs and symptoms of infection, such as fever, chills, increased heart rate, and
changes in mental status.
3. Educate on proper techniques for handwashing and use of hand sanitizers
4. Assess the patient's skin for any breaks or lesions that could serve as entry points for
pathogens.
5. Ensure that the patient's immediate environment is kept clean and free from potential
sources of infection
GERD
Nursing Diagnosis: Impaired Comfort related to gastroesophageal reflux disease (GERD)
secondary to gastric acid irritation as evidenced by frequent episodes of heartburn,
regurgitation, and discomfort.
Nursing Interventions:
1. Administer prescribed medications such as antacids, proton pump inhibitors (PPIs), or H2
receptor antagonists as ordered to reduce gastric acid secretion and alleviate symptoms.
2. Instruct the patient to maintain an upright position after meals to reduce pressure on the
lower esophageal sphincter and minimize reflux.
3. Encourage relaxation techniques such as deep breathing exercises or guided imagery to
promote overall comfort and reduce stress, which can exacerbate GERD symptoms.
4. Encourage the patient to eat smaller, more frequent meals to prevent overeating and
reduce gastric pressure.
 5. Teach the patient about lifestyle modifications to manage GERD symptoms, including
dietary changes, weight management, and smoking cessation.
Nursing Diagnosis: Risk for Imbalanced Nutrition: More Than Body Requirements related
to gastroesophageal reflux disease (GERD) as evidenced by frequent episodes of heartburn,
regurgitation, and discomfort after meals.
Nursing Interventions:
1. Encourage small, frequent meals to prevent overeating and decrease gastric pressure.
2. Advise the patient to avoid lying down immediately after meals to reduce the risk of
reflux.
3. Instruct the patient to elevate the head of the bed during sleep to minimize reflux
episodes.
4. Administer prescribed medications such as proton pump inhibitors (PPIs) or H2 receptor
antagonists as ordered to reduce gastric acid secretion and alleviate symptoms.
5. Educate the patient about the importance of stress reduction techniques such as deep
breathing exercises or meditation, as stress can exacerbate GERD symptoms.
PYLORIS STENOSIS
Nursing Diagnosis: Impaired Nutritional Status related to difficulty in swallowing and
inadequate intake secondary to pyloric stenosis
Nursing Interventions:
1. Regularly assess the patient's intake and output, including frequency and characteristics
of vomiting, urine output, and signs of dehydration such as dry mucous membranes and
decreased skin turgor.
2. Offer oral rehydration solutions containing electrolytes and glucose to replace lost fluids
and prevent dehydration.
3. Administer antiemetic medications as prescribed to reduce vomiting episodes and
minimize fluid loss.
4. Position the patient in a comfortable and upright position to promote gastric emptying
and reduce the risk of aspiration during vomiting episodes.
5. Administer electrolyte replacement therapy as prescribed to maintain electrolyte balance.
Nursing Diagnosis: Risk for Imbalanced Fluid Volume related to vomiting secondary to
pyloric stenosis.
Nursing Interventions:
1. Regularly assess the patient's intake and output, including frequency and characteristics
of vomiting, urine output, and signs of dehydration such as dry mucous membranes and
decreased skin turgor.
2. Offer oral rehydration solutions containing electrolytes and glucose to replace lost fluids
and prevent dehydration.
3. Administer antiemetic medications as prescribed by the healthcare provider to reduce
vomiting episodes and minimize fluid loss.
4. Position the patient in a comfortable and upright position to promote gastric emptying
and reduce the risk of aspiration during vomiting episodes.
5. Administer electrolyte replacement therapy as prescribed to maintain electrolyte balance.
APPENDECITIS
Nursing Diagnosis: Acute Pain related to inflammation of the appendix secondary to
appendicitis, as evidenced by verbal reports of abdominal pain, guarding behavior, facial
grimacing, and elevated vital signs.
Nursing Interventions:
1. Conduct a comprehensive pain assessment including location, intensity, duration, and
exacerbating factors.
 2. Monitor vital signs including temperature, heart rate, blood pressure, and respiratory rate
regularly to detect changes indicating worsening condition or complications.
3. Assess for signs of peritonitis such as rebound tenderness, rigidity, and distension.
4. Initiate NPO (nothing by mouth) status as per physician's orders to rest the
gastrointestinal tract and reduce the risk of complications.
5. Encourage the patient to find a comfortable position that minimizes abdominal
discomfort, such as lying with knees bent or in a semi-fowler's position.
Nursing Diagnosis: Risk for Infection related to the presence of inflamed and potentially
ruptured appendix secondary to appendicitis
Nursing Interventions:
1. Adhere strictly to aseptic techniques during any procedures involving the patient,
including wound care, catheter insertion, and medication administration.
2. Monitor the patient's temperature, heart rate, and respiratory rate regularly to detect signs
of infection or sepsis.
3. Assess the surgical incision site regularly for signs of infection such as redness, swelling,
warmth, or purulent drainage.
4. Perform wound care using sterile technique as ordered and change dressings as indicated.
5. Administer prescribed antibiotics promptly and ensure that the full course of treatment is
completed to eradicate the infection.
INTUSSUSCEPTION
Nursing Diagnosis: Acute Pain related to bowel obstruction secondary to intussusception.
Nursing Interventions:
1. Regularly assess the patient's pain using a pain assessment scale appropriate for their age
and developmental level. Monitor for verbal and non-verbal cues of pain such as
grimacing, guarding, and restlessness.
2. Administer prescribed pain medications promptly to alleviate discomfort and promote
comfort.
3. Assist the patient in finding a comfortable position that may help relieve abdominal
discomfort. For infants, swaddling or holding may provide comfort. For older children
and adults, positioning with knees bent or lying on the side with knees drawn up may
help.
4. Offer distraction techniques such as music, games, or engaging conversation to divert the
patient's attention from pain and promote relaxation.
5. Teach deep breathing exercises and relaxation techniques to help the patient cope with
pain and reduce anxiety.
Nursing Diagnosis: Risk for Impaired Tissue Perfusion related to compromised blood flow
secondary to intussusception.
Nursing Interventions:
1. Regularly assess vital signs, including blood pressure, heart rate, and peripheral
perfusion, to detect changes indicating compromised tissue perfusion.
2. Evaluate peripheral pulses, skin color, temperature, and capillary refill time frequently to
monitor for signs of decreased tissue perfusion.
3. Ensure adequate hydration by administering intravenous fluids as prescribed to support
perfusion and prevent hypovolemia.
4. Position the patient in a comfortable position that promotes optimal circulation, such as
elevating the lower extremities slightly to facilitate venous return.
5. Provide meticulous skin care to prevent pressure ulcers, particularly in immobile patients
or those with compromised perfusion.
HIRSCHPRUNG
Nursing Diagnosis: Impaired bowel elimination related to altered motility and obstruction
secondary to Hirschsprung's disease.
Nursing Interventions:
1. Monitor and document the frequency, consistency, and characteristics of bowel
movements to establish a baseline and detect any changes. This includes observing for
signs of constipation, diarrhea, or abdominal distension.
2. Implement comfort measures such as positioning the patient in a comfortable position to
relieve abdominal discomfort, administering prescribed pain medications as needed, and
providing warmth through blankets or heating pads to ease abdominal cramping.
3. Encourage adequate fluid intake unless contraindicated.
4. Encourage the patient to engage in appropriate physical activity as tolerated to promote
bowel motility and relieve constipation.
5. Monitor electrolyte levels regularly and administer oral or IV fluids as prescribed to
prevent dehydration or electrolyte imbalances.
Nursing Diagnosis: Risk for Impaired Nutritional Status related to altered gastrointestinal
function secondary to Hirschsprung's disease.
Nursing Interventions:
1. Conduct a thorough assessment of the child's nutritional status, including dietary intake,
weight trends, growth parameters, and signs of malnutrition.
2. Ensure adequate intake of essential nutrients, calories, and fluids to support growth and
development.
3. Monitor the child's bowel function closely, including frequency, consistency, and any
signs of constipation or diarrhea.
4. Encourage the child to drink plenty of fluids to prevent dehydration and maintain
hydration status
5. Address any feeding challenges or difficulties the child may experience, such as oral
aversion, feeding refusal, or dysphagia.
INJURY TO THE EYE
Nursing Diagnosis: Risk for Impaired Vision related to injury to the eye
Nursing Interventions:
1. Regularly assess the affected eye for signs of inflammation, infection, or any changes in
visual acuity.
2. Ensure that the affected eye is protected from further injury. This may include covering
the eye with a protective shield or patch
3. Administer prescribed eye drops, ointments, or oral medications to manage pain, prevent
infection, and promote healing.
4. Encourage the patient to rest with the affected eye closed to reduce strain and promote
healing.
5. Provide comfort measures such as applying cold compresses or providing pain relief as
needed.
Nursing Diagnosis: Acute Pain related to injury to the eye secondary to trauma or
inflammation.
Nursing Interventions:
1. Conduct a comprehensive pain assessment, including location, intensity (using a pain
scale), quality, and factors that aggravate or alleviate the pain.
2. Administer analgesic medications as prescribed by the physician, such as acetaminophen
or nonsteroidal anti-inflammatory drugs (NSAIDs), to alleviate pain and discomfort.
3. Apply cold compresses or ice packs wrapped in a cloth to the affected eye to reduce
swelling and provide localized pain relief.
4. Assist the patient with positioning to promote comfort, such as elevating the head of the
bed or providing extra pillows for support.
5. Teach relaxation techniques and distraction methods to help the patient cope with pain
effectively.
DISORDER OF THE EAR
Nursing Diagnosis: Impaired Hearing related to disorder of the ear
Nursing Interventions:
1. Conduct a comprehensive assessment of the patient's hearing ability using appropriate
tools such as pure tone audiometry, tympanometry, and speech audiometry.
2. Regularly monitor changes in hearing status and document findings to track progression
or improvement of the disorder.
3. Teach strategies for conserving hearing ability, such as avoiding exposure to loud noises,
using ear protection, and maintaining ear hygiene
4. Assess the need for hearing aids, cochlear implants, or other assistive listening devices
and facilitate their acquisition.
5. Encourage the use of alternative communication methods such as sign language, lip-
reading, or writing for patients with severe hearing impairment.
Nursing Diagnosis: Risk for Infection related to disorder of the ear
Nursing Interventions:
1. Conduct a thorough assessment of the patient's ear, including inspection for signs of
inflammation, discharge, and pain.
2. Monitor vital signs and laboratory findings indicative of infection, such as elevated white
blood cell count or presence of pathogens in cultures.
3. Instruct the patient on proper ear hygiene practices, including gentle cleaning with mild
soap and water, and avoidance of inserting foreign objects into the ear canal.
4. Administer prescribed antibiotics, antifungals, or analgesics as ordered by the healthcare
provider to treat or prevent ear infections and alleviate associated symptoms.
5. Encourage the patient to rest in a comfortable position that minimizes pressure on the
affected ear.