NOC Knowledge Disease Process

Assess knowledge of disease, signs and symptoms of relapse, dietary and activity aspects of care, medication administration and side effects, monitoring urine and VS. Assess level of anxiety and need for support in care of ill child and possible relapse. Teach parents and child about the cause of the child's illness and treatment to expect. Encourage questions and allow time for discussion. Teach about medication administration including side effects of steroids and immunosuppressives that...

NIC Grief Work Facilitation

Promotes movement through grieving process by utilizing defense mechanisms that have worked in the past. Reinforces that SIDS is an unpreventable, unexplainable sudden death of an infant and that no one can be blamed. Provides optimal level of accurate information for medical examiner. Enhances the parental support system and enhances communication. environment, for the initial shock and disbelief that are expected behaviors of grief. Therapeutic communication assists the parents to express...

NOC Risk Control Hearing Impairment

Assess history of chronic otitis media, brain infection, use of ototoxic drugs, rubella or other intrauterine infections (viral), congenital defects of ear or nose, presence of deafness in family members, hypoxemia and increased bilirubin levels in low-birth weight infants. Assess for auditory acuity Infant failure to waken to sounds no response to loud noise no response to sound made out of visual field lack of startle and blink reflexes failure to turn head to localize sound by 6 months...

NOC Child Development Infant

Assess behavioral states of the infant including periods of quiet and active sleep, habituation, orientation, and self-consoling ability. Introduce one caregiving intervention at a time, observing responses allow for time out if infant displays stress signals, such as finger splaying, grimacing, tongue extension, worried alertness, spitting up, back arching, gaze aversion, yawning, hiccuping, color changes, or changes in cardiac or respiratory functioning. overstimulating infant continuously...

Anticipatory Grieving

Related to (Specify perceived potential loss of child by parents perceived potential loss of physiopsychosocial well-being by child.) Defining Characteristics (Specify expression of distress of potential loss, inevitable kidney failure, kidney dialysis, premature death of child.) Goal Parents and child will begin to work through the grief process by (date and time to evaluate). Outcome Criteria V Parents will verbalize stages of grief. V Parents and child will identify 3 positive coping...

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...

NOC Symptom Control

Assess presence of acute abdominal pain with loud crying and drawing knees up to chest which may be episodic, vomiting, passage of a brown stool followed by red, currant jelly-like stool, pallor, irritability. constipation, episodes of vomiting and colic in older child. Provide NG tube attached to suction, IV fluids to decompress bowel and maintain hydration status and maintain patency of therapy as ordered (specify). Note bowel elimination and stool characteristics and ability to eliminate...

NIC Self Esteem Enhancement

Provides opportunity to vent feelings and reduce negative feelings about changes in appearance. Reveals responses to body image changes and possible poor adjustment to chances. Promotes trust and demonstrates respect for child. Encourages acceptance of the child with special needs (must deal with long-term steroid therapy and its side effects, lifelong activity restrictions). Provides correct information to assist in dealing with negative feelings about body. Promotes child's sense of wellbeing...

See Imbalanced Nutrition Less Than Body Requirements

Related to (Specify loss of appetite and or pain in mouth induced malabsorption or enteropathy caused by abdominal radiation, chemotherapy, abdominal surgery, or frequent antibiotic use and anorexia-inducing substances secreted by tumor cells xerostomia (irreversible dryness of mouth , destruction of microvilli of taste buds and or lining of salivary glands all can be caused by radiation therapy .) Defining Characteristics (Specify anorexia, nausea, vomiting, stomatitis, mucositis, decreased...

Insulindependent Diabetes Mellitus Introduction

Insulin-dependent diabetes mellitus (IDDM) is a metabolic disorder caused by a deficiency of insulin. The deficiency is thought to occur in those individuals who are genetically predisposed to the disease and who have experienced a precipitating event, commonly a viral infection or environmental change, that causes an autoimmune condition affecting the beta cells of the pancreas. It is treated by injection of insulin and regulation of diet and activity that maintain body functions....

Additional Nursing Diagnoses Anxiety

Related to (Specify threat to self-concept, change in health status of child, hospitalization and surgery of child.) Defining Characteristics (Specify increased apprehension and expressed concern about future infertility and effect on body image, presence of empty scrotum and smaller size, expressed concern about impending surgery or need for future surgery and procedure performed to correct abnormality.) Goal Client will experience decreased anxiety by (date and time to evaluate). Outcome...

NOC Self Esteem

Assess child for feelings about wearing brace, long-term treatments, restrictions in lifestyle, inability to keep up with peers and participate in activities. Encourage expression of feelings and concerns and support child's communications with parents, peers and teachers. appliance. Maintain positive environment and promote activities that are allowed (sports, play, games). Assist with plan for independence in ADL, application and removal of appliance, selection of shoes and clothing to wear...

NOC Family Normalization

Assess family ability to cope with child, stress on family relationships, developmental level of family, response of siblings, knowledge of health practices, family role behavior and attitude about long-term care, economic pressures, resources to care for long-term condition and grieving Provides information about family attitudes and coping abilities that directly affect the child's health and feeling of wellbeing chronic condition affecting a child in a family may strengthen or strain...

NOC Mobility Level

Assess muscle tone, strength, mass joint mobility, pain, stiffness, swelling ability to move and activity level in performing ADL (specify when). restrictions, imposed immobility by braces, casts, traction, splints. Assess sensory (diminished sensation and numbness) and motor (gait and balance) function of extremities presence of paralysis, fracture, surgical correction of musculoskeletal abnormalities. immobilization on body systems constipation, skin breakdown, urinary retention,...

Flow Chart For Insulindependent Diabetes Mellitus

IN5UUN-DEPENDENT DIABETES MELLfTUS < IDDM> Genetic factor (autosomal recessive HLA-associated gene) Precipitating event (viral bacterial infection, chemical or dietary exposure) Autoimmune reaction causing destruction of befa cells in pancrease Use of protein and fat stores for energy Ketoacidosis (DKA) Kussmaul respirations Ce II u la r death I K* Cardiac dysfunction Inability of glucose to enter ce lis Inability to store glucose as glycogen Inability to metabolize glucose Common symptoms...

Flow Chart For Leukemia And Lymphoma

Leukemia Plan Care

Allows for venting of feelings to determine need for information and support, and relieves guilt and anxiety. Enhances family understanding of medical regimen and Promotes understanding of importance of making child one of the family and the adverse effects of overprotection of the child. Empowers the clients to take control of coping methods and find alternatives. COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved.

Flow Chart For Meningitis

Multiple Sclerosis Graph

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NOC Sleep

Assess sleep patterns and changes, nap times and frequency, sleep problems, pattern of awakenings and reason. elevation, restlessness caused by pain, dyspnea, other signs and symptoms of an illness. Assess for fatigue, irritability, weakness, lability, yawning. Place infant 0-6 months on back or side-lying position for sleep, utilizing positioning aids such as rolled blankets to maintain desired position infants with gastroesophageal reflex, premature infants, and infants with specific upper...

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....

NOC Family Coping

Prevents attack before it begins and increases ventilation. Promotes compliance in order to prevent attack and maintain wellness action of drug . hypersensitization regimen. Offers support to families with child suffering from asthma. Provide an opportunity for the family to adjust to the diagnosis anticipate the normal grief reaction of loss of the perfect child. Explore the family's feelings regarding the child and the diagnosis. Assist the family to explore specific feelings regarding guilt,...

Flow Chart For Fractures

Allows for movement without disturbing traction. Provides and promotes social interactions. Provides information to assist with coping with immobility. Ensures that amount of activity is not exceeded and will not affect traction. Promotes positive response to treatment. Associated soft tissue contusion Rupture of vessels and bleeding into tissues and around bone Periosteum torn Swelling Hematoma Diminished function Rough handling Pulling or twisting Physical abuse Surgical realignment and...

Anxiety

Related to Change in health status change in environment threat to self-concept situational crisis specify . Defining Characteristics Increased apprehension fear helplessness uncertainty distress over hospitalization restlessness expressed concern over procedures, pain, loss of control, separation from significant others crying clinging refusal to interact with staff, changes in VS, financial stresses caused by required absence from employment specify child's behavior . Goal Child and family...

Neurologic System Basic Care Plan Introduction

The neurologic system includes the central nervous system CNS consisting of the cerebrum, cerebellum, brain stem, and the spinal cord the peripheral nervous system consisting of the motor efferent and sensory afferent nerves and the autonomic nervous system ANS consisting of the sympathetic and parasympathetic systems that provide control of vital body functions. Alterations in the neurologic system affect the process of receiving, integrating, and responding to stimuli that enter the system....

Nursing Diagnoses Ineffective Airway Clearance

Related to Specify tracheobronchial infection, obstruction, secretions. Defining Characteristics Specify, e.g., abnormal breath sounds fine or coarse crackles, rhonchi, wheezes, changes in rate or depth of respirations, tachypnea, cyanosis, fever, provide data. Related to Decreased energy and fatigue. Defining Characteristics Specify, e.g., ineffective cough with or without sputum, labored respirations, inability to feed self, sleeplessness, lack of activity, weakness. Goal Infant child will...

NOC Thermoregulation

Assess temperature via axillary method in infants and children to age 5 years, oral in children 5 to 6 years and older, depending on the individual child's ability to safely and accurately keep the thermometer in their mouth check for malaise or lethargy and compare to normal ranges for age or low grade or high elevations associated with specific microorganisms or diseases. Provides information about temperature changes caused by high susceptibility to fluctuations in infants and young children...

Nephrotic Syndrome Introduction

Nephrotic syndrome is an alteration of renal function caused by increased glomerular basement membrane permeability to plasma protein albumin . Alterations to the glomerulus result in classic symptoms of gross proteinuria, hypoalbuminemia, generalized edema anasarca , oliguria, and hyperlipidemia. Nephrotic syndrome is classified either by etiology or the histologic changes in the glomerulus. Nephrotic syndrome is also classified into 3 types primary minimal change nephrotic syndrome MCNS ,...

NOC Coping

Assess level and manifestations of Provides information needed for anxiety in parents and child. interventions and clues to Allow parents and child to express Provides opportunity to vent fears and concerns and to ask feelings and secure information questions about disease and what to reduce anxiety. to expect. Provide supportive and nonjudgmental Promotes trust and reduces Encourage parents to stay with Reduces anxiety by allowing child, allow open visitation and presence and involvement in...

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 patterns...

Flow Chart For Osteomyelitis

Promotes exposure to various activities and changes of environmental stimuli. Promotes independence and allows some control over the situation. 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 08 48 PM PST GMT...

Vesicoureteral Reflux Introduction

Vesicoureteral reflux is defined as a retrograde or backflow of urine into the ureters. The diagnosis for VUR rarely occurs after 5 years of age. The etiology of VUR is categorized into two types, primary and secondary reflux. Primary reflux is caused by an inadequate valvular mechanism at the ureterovesical junction and is not associated with any obstruction or neurogenic bladder. The inadequate valve in primary reflux is caused by the shortened submucosal tunnel that shortens bladder filling....

Hypertension Introduction

Hypertension in children is reflected by the consistent readings of the systolic and or diastolic blood pressure at the level of or above the 95th percentile for age and sex. It may be primary or secondary. Fifty to 80 of secondary hypertension is caused by renal parenchymal disease therefore, infants and children with hypertension and adolescents with severe hypertension need to be evaluated for renal pathology. Hypertension in children is of particular concern because of its close association...

Outcome Criteria

V Clients report decreased anxiety specify, e.g., no anxiety or mild anxiety only . NOC Anxiety Control Assess level of anxiety and need for information that will relieve anxiety. Ask parents to rank their feelings of anxiety as none, mild, moderate, severe, or feelings of panic. Encourage expression of concerns and questions about condition, to discuss feelings about appearance of infant. Provide an accepting environment and attitude and handle the infant in a gentle, caring way. Communicate...

Flow Chart For Chronic Renal Failure

Chronic pyelonephritis Chronic glomerulonephritis Nephritis Polycystic kidney Nephrotic syndrome Retention of protein metabolism byproduct Reduced glomerular filtration rate Progressive intolerance to fluid electrolyte excesses or restrictions _I_ Inability to concentrate urine Inability to filter albumin Hypernatremia Hypocalcemia Hy pe rpho5phatem ia Hyperkalemia Renal osteodystrophy Hypertension congestive heartfailure Anemia gastrointestinal bleeding Pneumonia pulmonary edema Peripheral...

NOC Risk Control

Assess blood pressure for alterations administer antihypertensives ordered specify . Assess I amp O, electrolyte panel, and creatinine administer diuretics as ordered specify . Assess RBC, Hct, Hgb and administer iron and transfusion of packed red blood cells, as ordered specify . Assess bone pain and deformities affecting ambulation and activities administer supplemental vitamin D, calcium and alkalizing agents, as ordered. Assess presence of acidosis by pH, bicarbonate losses and administer...

Additional Nursing Diagnoses Fear

Related to Invasive, painful procedure, risk of harm, separation from parents, fear of needles, and fear of exposure. Defining Characteristics Specify Apprehension, expressed concern over impending procedure. In children increased motor activity, inattention, withdrawal, crying, clinging to parent s , verbal protests . Goal Child and parents will exhibit decreased anxiety by date time to evaluate . Outcome Criteria V Child will not cry, cling to parents, or protest. V Parent s will verbalize...

NOC Fluid Balance

Assess food frequency and 24 hour recall, oral fluids, medications, food likes and dislikes, financial and cultural influences, food allergies, food preparation methods. Assess onset of nausea and vomiting, quality, quantity and presence of blood, bile, food, and odor. Assess relationship of nausea and vomiting to meals, time of day or activities, and associated triggers. Assess for presence of associated symptoms diarrhea, fever, ear pain, UGI symptoms, vision changes, headache, seizures, high...

Urinary Tract Infection Introduction

Urinary tract infection UTI is defined as infection located in the lower tract bladder or urethra or in the upper tract ureters or kidneys . The peak incidence of UTI observed in children occurs between 2 and 6 years of age, but can be observed at any age. The incidence of UTI in children also varies by gender females have a 10 to 30 greater risk of developing a UTI males have a 50 greater risk of developing a recurrent UTI and during the newborn-age range only, male infants are at a greater...

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...

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...

Deficient Knowledge

Related to Lack of information about the disease. Defining Characteristics Specify request for information about initial and long-term treatment, management of the therapy, and modification of activities. Goal Clients will obtain knowledge about the illness by date and time to evaluate . Outcome Criteria V Parents verbalize understanding of the four stages of the disease. V Parents and child if applicable verbalize understanding of treatment plan specify . NOC Knowledge Disease Process Assess...

Otitis Media Introduction

Otitis Media OM is an infection of the middle ear most common in infants and toddlers during the winter months. It may be either viral or bacterial. Inflammatory obstruction of the eustachian tube causes accumulation of secretions in the middle ear and negative pressure from lack of ventilation. The negative pressure pulls fluid and microorganisms into the middle ear through the eustachian tube resulting in otitis media with effusion. The illness usually follows a URI or cold. The older child...

Osteogenic Sarcoma Introduction

Osteogenic sarcoma is a primary malignancy of the bone with the metaphysics of the long bones most commonly affected. These include the femur, humerus, and tibia. Metastasis most commonly affects the lungs but may involve other organs. The disease most commonly occurs in children over 10 years of age. Treatment consists of amputation of the limb with chemotherapy before and or following surgery, or a bone and joint replacement in selected children to salvage the limb with chemotherapy before...

Flow Chart For Acute Rheumatic Fever

Rheumatic Fever Chart

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Dysfunctional Grieving

Related to Loss of child as result of specify accident, SIDS, absence of anticipatory grieving . Defining Characteristics Specify expressed distress anger guilt over loss difficulty in expressing loss sadness crying sudden, unexplained Promotes comfort and minimizes emotional distress related to invasive procedures action of EMLA . Promotes comfort and love of child to reduce anxiety. Promotes interactions and attitude of caring within family. Promotes understanding of physical needs of dying...

Flow Chart For Bronchopulmonary Dysplasia

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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...

Flow Chart For Asthma

Flow Chart Asthma Care Plan

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Additional Nursing Diagnoses Activity Intolerance

Defining Characteristics Specify presence of circulatory respiratory problem, verbal complaint of fatigue or weakness, needs to rest after short period of play. Related to Imbalance between oxygen supply and demand. Defining Characteristics Abnormal heart rate or blood pressure response to activity, exertional dyspnea specify . Goal Child will tolerate increased activity. Outcome Criteria V Specify for this child the activity level that is optimal within the limitations of the congenital heart...

Nursing Diagnosis 1 Ineffective Airway Clearance

Related to Bronchospasm and increased pulmonary secretions. Defining Characteristics Shallow respirations with expiratory wheeze, respiratory rate 34, SaO2 88 , peak flow 200L min after medications. Goal Client will maintain a clear airway throughout admission. Outcome Criteria V Respiratory rate less than 24, lungs clear to auscultation, SaO2 greater than 95 . NOC Respiratory Status Ventilation Assess respirations for rate count one full minute , pattern depth, and ease, auscultate lung...

Flow Chart For Hepatitis

Flowchart Hepatitis

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Constipation

Related to Less than adequate dietary intake and bulk. Defining Characteristics Specify frequency less than usual pattern, hard, dry formed stool, decreased bowel sounds, straining at stool, decreased amount of stool, change from human to cow's milk in infancy. Defining Characteristics Specify environmental changes school , stool withholding in young children, lack of privacy, inability of leisurely use of bathroom, not using bathroom when urge is felt by school-age children. Related to Less...

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 .

Impaired Oral Mucous Membrane

Defining Characteristics Specify stomatitis, oral ulcers, hyperemia, oral pain or discomfort, oral plaque. Prevents transmission of infective agents to the immunosuppressed child. To assess potential intestinal obstruction from vincristine-induced adynamic ileus. To prevent straining with bowel movements. Promotes understanding and cooperation. pathogens in the immunosuppressed child. associated with exposure or trauma to the abdominal site preoperatively and surgical site postoperatively....

Flow Chart For Appendicitis

Compression of blood vessels Ischemia Ulceration of epithelial lining of appendix Perforation of appendix Abscess of appendix site Rupture of appendix Surgical drainage of peritoneal cavity Abdominal decompression Peritonitis Intestinal obstruction Hypovolemic shock 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...

Tonsillitis Introduction

Tonsillitis is an infection of the tonsils, which consist of pairs of lymph tissue in the nasal and oropharyngeal passages. Bacterial or viral pharyngitis usually precedes infection of the tonsils. Inflammation and edema of the tonsillar tissue creates difficulty swallowing and talking, and forces the child to breathe through the mouth. Advanced infection can lead to cellulitis in adjacent tissue or formation of an abscess which may require drainage. The tonsils removed during a tonsillectomy...

Disorganized Infant Behavior

Related to Environmental stimulation. Defining Characteristics Specify, e.g., alterations in heart rate, respirations, color changes, erratic body movements, difficulty with feedings or prolonged periods of wakefulness. Goal Infant will display increased organization of behavior by date time to evaluate . Outcome Criteria V Infant demonstrates quiet alert state and ability to habituate to environmental stimuli. V Color changes with handling and movement are decreased. V Demonstrates smoother...

Impaired Urinary Elimination

Related to Specify mechanical trauma urethroplasty . Defining Characteristics Specify dysuria, frequency, urgency, retention, bladder spasms, inadequate output, edema of the urethra. Goal Client will experience improved urinary elimination by date and time to evaluate . Outcome Criteria V Client voids through new or corrected urinary meatus after catheter is removed. V Unable to palpate bladder after voiding. NOC Urinary Elimination Provides information and skill in caring and maintaining...

Flow Chart For Nephrotic Syndrome

Infections Nephrotic Syndrome

Provides safety measure to prevent complications in a child that is immunosuppressive. Prevents risk of infection that may precipitate a relapse. Positive reinforcement enhances desire to learn new skills. Promotes return to usual patterns of living. disease process and importance of compliance with therapy to prevent exacerbation. COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved. COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved. COPYRIGHT 2005 by Thomson Delmar...

Deficient Knowledge Parents Prevention Of Om

Related to Specify, e.g., lack of information lack of recall of information misinterpreted information. Defining Characteristics Specify, e.g., parents allow smoking in the home so child is exposed to passive smoke infant is bottle-fed and sometimes the infant lies flat with the bottle propped. Goal Parents will gain knowledge about prevention of OM by date time to evaluate . Outcome Criteria V Parents verbalize understanding of OM. V Parents verbalize understanding of 3 factors that may...

Ineffective Breathing Pattern

Defining Characteristics Specify shortness of breath, tachypnea, fremitus. Related to Decreased lung expansion. Defining Characteristics Specify apnea, dyspnea, respiratory depth changes. Related to Tracheobronchial obstruction. Defining Characteristics Specify dyspnea, head bobbing in infant, drooling, tachypnea, abnormal arterial blood gases, cyanosis skin, circumoral, mucous membranes , nasal flaring, respiratory depth changes, use of accessory muscles and retractions, altered chest...

Flow Chart For Inflammatory Bowel Disease

Inflammatory Bowel Disease

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Flow Chart For Glomerulonephritis

Post-streptococcal infection group A, beta-he molytic Release of material from the organism into the circulation tantigen Proliferation of endothelial cells lining glomerulus and cells behveen endothelium and Swelling of capillary membrane and infiltration with leukocytes Increased permeability of base membrane Occlusion of the capillaries of glomeruli Decreased glomerular filtration rate Decreased ability to fomi filtrate from Retention of water and sodium Reduced circulatory volume...

Flow Chart For Gastroenteritis

Flow Chart For Gastroenteritis

For enteritis as a basis for treatment reveals occult blood in stool in severe inflammation of bowel. Prevents additional irritation to rectum. Prevents use of medications that may exacerbate condition. Treats vomiting and additional fluid loss and promotes rest. Prevents possible fluid imbalance complication which leads to dehydration. COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved. COPYRIGHT 2005 by Thomson Delmar Learning. All Rights Reserved. COPYRIGHT 2005 by Thomson Delmar...

Flow Chart For Hernia

Flow Chart For Hernia

Provides assurance and comfort to parents in giving care. 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 00 48 PM PST GMT -08 00 123 amp docid 35 DELMAR'S PEDIATRIC NURSING...

Flow Chart For Tuberculosis

Inhalation into respiratory tract Organisms deposited in lung periphery Inflammatory response Polymorphonuclear leukocytes accumulate Polymorphonuclear leukocytes replaced by macrophages that engulf bacteria Formation of g ia nt g ra nu la r eel Is that surround foreign cells Calcification of lesion Formation of granuloma tubercle Scar tissue encapsulates tubercle to separate it from body Sensitization of T lymphocytes Positive tuberculin skin test Bacilli spread throughout lung Caseous...

Imbalanced Nutrition Less Than Body Requirements

Related to Specify inability to ingest or digest food or absorb nutrients because of biologic or psychological factors. Defining Characteristics Specify loss of weight with adequate intake, lack of interest in food, anorexia, nausea, vomiting, diarrhea, congenital defect of gastrointestinal system, regurgitation, abdominal pain, dysphagia, inability in infant to suck and swallow, failure to thrive, malabsorption syndromes, growth and developmental changes food jags, fads, ritualisms, rejection...

Flow Chart For Allergic Rhinitis

Chart Explain Latex Allergy

Provides control of the symptoms when exposed to allergens. Hands found to be most common carrier of microorganisms. Prevents transmission of microorganisms. Prevents exposure to the infectious agent, although isolation is not realistic within a family. Ensures compliance with medication regimen to control symptoms and prevent infection. Ensures effective treatment of bacterial infection for prompt response within 24 hours after antibiotic administration. Allays child's anxiety and fear caused...

Risk For Deficient Fluid Volume

Related to Inadequate oral intake, excessive losses through abnormal route. Defining Characteristics Specify, e.g., child states it hurts to drink, decreased intake specify amount post-tonsillectomy risk for hemorrhage. Goal Child will not experience deficient fluid volume by date time to evaluate . Outcome Criteria V No signs of bleeding from operative site. NOC Fluid Balance Monitor skin turgor and moisture of mucous membranes. Observe post-tonsillectomy client for signs of bleeding assess...

Flow Chart For Cardiac Dysrhythmias

Chart Dysrhythmia Drugs

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Flow Chart For Hypertension

Flow Chart For Hypertension

Provides specialized guidance if needed to ensure compliance and success. 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 5 48 31 PM PST GMT -08 00 123 amp docid 12 DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. 2005 UNIT 2 - CARDIOVASCULAR SYSTEM CHAPTER 2.5 - HYPERTENSION...

Flow Chart For Congestive Heart Failure

Heart Failure Flowchart

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NOC Respiratory Status Gas Exchange

Assess respiratory rate, depth, and Reveals respiratory effort, rate and ease, count for one minute , depth baselines or deviations , presence of dyspnea, tachypnea, chest symmetry of movements, and use of movement, periods of apnea specify accessory muscles, which affect the frequency . amount of air that reaches the Monitor SaO2 continuously with pulse oximeter alarms turned on specify if using TCM to obtain TcPa02 and TcPaC02 levels . Assess ABGs for 0 pH, D Pa02, D PaC02 as obtained....

Common Nursing Diagnoses Decreased Cardiac Output

Related to Mechanical factors alterations in preload alterations in afterload alterations in inotropic function of heart. Defining Characteristics Variations in hemodynamic readings BP, CVP hypovolemia jugular vein distention oliguria decreased peripheral pulses cold, clammy skin crackles dyspnea specify . Related to Electrical factors alterations in rate alterations in rhythm alterations in conduction. Defining Characteristics Arrhythmias, ECG changes, bradycardia, changes in contractility...

Flow Chart For Congenital Heart Disease

Shunting from pulmonary artery through ductus Flow from ascending to descending aorta through collateral circulation Hypotension Claudication Cool lower extremities, weak pulses in lower body Pulse and blood presure changes in upper and lower extremities Hypertension Bounding pulse lower body

Delayed Growth And Development

Related to Separation from significant others specify, parents, siblings, peers and or primary caretaker . Defining Characteristics Ages 6 to 30 months specify, crying, screaming, withdraws from others, inactive, sad, detachment behaviors, regressive behaviors 3 to 6 yrs. specify, temper tantrums, refusal to comply with hospital routine treatments, crying, refusal to eat 6 to 12 yrs. specify, express feelings of loneliness, boredom, isolation, depression, worry about absence from school 13 to...

NOC Anxiety Control

Assess child's and parents' level of anxiety, child's developmental level, understanding of illness, and reason for hospitalization, and responses to this and previous hospitalizations during admission. Assess social and emotional history of child and family for strengths and successful coping ability. Allow expression of feelings and concerns about illness and procedures and listen individually to child and parents. Provide a calm, accepting environment and avoid rushing through interactions...

Pediatric Asthma Case Study

A 14-year-old African-American female is brought to the pediatrician's office by her mother. She has just started running on her high school track team, but has been complaining to her mother that her running feels different this year. When she ran in middle school she could race longer distances without becoming winded. She now says her chest burns and she is running fewer miles before she has to stop to catch her breath. Her girlfriend told her she could hear her wheezing and she should go to...

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 suggested...