Nursing priorities for Antonio Valencia, a 4month old boy includes: deficit in fluid volume and ineffective clearance of airway.
Nursing priorities for Simon Green, a 15th month old boy: prevent seizure activity and maintain respiratory function.
Nursing priorities for Alla Jones, a 5years old girl: ineffective pattern of breathing and ineffective airway clearance.
Nursing priorities for Alex Baka, a 12years old girl: acute pain and possibility of poor fluid volume.
Deficit in fluid volume
Associated risk factors: immense loss of fluid (mouth breathing, fever, profuse diaphoresis, vomiting) and reduced oral intake
Expected outcome: demonstration of fluid balance supported by clammy mucous membrane, improved skin turgor, steady vital signs and rapid refill of the capillaries
Associated risk factors: fatigue, decreased energy, edema formation, raised production of sputum and bronchial inflammation.
Evidence by: rate alterations, respirations depth, abnormal sound of breathing, accessory muscle ulitization, cyanosis, dyspnea, ineffective or effective cough along with or without production of sputum.
Expected outcome: show behaviors to accomplish clearance of airway and display clear breathing sounds and absence of cyanosis and dyspnea.
Developmental nursing care includes weight gain and easing the feeding difficulties. This child should receive adequate hydration and nutrition to support positive weight gain.
Prevent seizure activity
Maintain respiratory function
Developmental nursing care includes understanding the psychosocial needs of this child. Hospitalization may restrict the child’s independence and regular routine. A developmental nursing care, for example: loss of control could be a nursing strategy that allows Simon Green to choose when to play and what foods to have.
Ineffective breathing pattern
Ineffective airway clearance
Nursing interventions for ineffective breathing pattern
It is said to be the middle stage for preschoolers and school age. This is the case of a 5years old girl, who is suffering from Asthma. So, nursing plan should include training of proper inhaler management, along with toilet training that supports their self-esteem.
Poor fluid volume
Developmental nursing care should include knowledge enhancement. This means a 12 years child will be much interested to understand his/her condition. So, in this case, nurse might inform her about her health condition as a visual presentation and definitely inform her that she will become physically fit soon and can play like children if she follows prescribed medications and rules properly.
Ashley, M. (2011). Seizures. Leicester: Matador.
Busse, W. (2004). Management of asthma exacerbations. Thorax, 59(7), pp.545-546.
da Silva, V., de Oliveira Lopes, M., de Araujo, T., Ciol, M. and de Carvalho, E. (2008). Clinical indicators of ineffective airway clearance in children with congenital heart disease. Journal of Clinical Nursing.
Judd, S. (2008). Respiratory disorders sourcebook. Detroit, MI: Omnigraphics.
Schmölzer, G. (2012). Respiratory function monitor guidance during respiratory support in the delivery room. Resuscitation, 83, p.e82.
Urso, D. (2014). Acute asthma exacerbations: an overview. RHC, 5(3).
Wasnik, N., Agrawal, V., Yede, J., Gupta, A. and Soitkar, S. (2015). Role of supplemental oxygen in reducing surgical site infection in acute appendicities: Our experience of sixty four cases.International Journal of Biomedical and Advance Research, 6(2), p.124.
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