Adventist University of the Philippines

College of nursing
Level 2
NURSING CARE PLAN
Student info

Patient Information
Name of Patient- Gender- Male Age- 1 yr 7 mo
Address-
Civil Status-Single
Education Attained-Pedia Date admission 03-03-19 3:04 AM
Occupation-Pedia Attending Physician--
Chief Complaint-Body weak , Fever, Irritable, Vomiting
Admitting Diagnosis/Impression-Systemic Viral Infection w/ infection
Final Diagnosis- 2 days D+c, vomiting of 16x at ½ cup, mixed with food and milk was in
PCGH, 1 day before the symptoms continue , and came to MAMC

History Of present Illness

Past Medical and/or OB History- Born on Jul-23-17 , has Hx of Asthma
Family Medical History- N/A

For Pediatric Clients Delivery History

Feeding History- Breast Milk, current MF
Immunizations History- N/A
Past Childhood Diseases- Asthma
Age-appropriate play/activities- Teach your child to sing his/her favourite nursery rhyme and
make up a dance or movement to go along with it. Give your child blocks to sort by shape or
colour. Let him/her use magnetic alphabets to form words and teach him/her to pronounce
them. Go to the playground with a friend’s child and help your children learn to play together.
Play glove or finger puppets to encourage communication.

PRINCIPLES/Theory OF GROWTH AND DEVELOPMENT

Task/crisis according to Sigmund Freud- oral phase , the mouth, sucking, swallowing, etc
Discussion of task/crisis in relation to the patient present condition- Patient in confined within
Pediatric ward and is limited by space and normal hose setting environment
Tast crisis/ according to erik erikson-autonomy vs shame, a sense for self control and
adequacy
Discussion of task/crisis in relation to the patient Present condition- Patient cannot be
unattended without a familiar guardian for extended time span , ro reduce occurance of any
distress

SIMPLE PATHOPHYSIOLOGY OF THE DISEASE PROCESS

Etiology-Bacterial and viral infections can cause similar symptoms such as coughing and
sneezing, fever, inflammation, vomiting, diarrhea, fatigue, and cramping -- all of which are
ways the immune system tries to rid the body of infectious organisms.
 Predisposing factors-immunodeficiency syndrome, poor hygiene, genetic
(ideologic) factors.

HEALTH ASSESSMENT BASED ON GORDON'S FUNCTIONAL HEALTH PATTERNS

• Health Maintenance perception Pattern
• Health Maintenance perception pattern
Before Hospitalization During Hospitalization
Cigarette smoking- NO Cigarette smoking- NO
Alcohol- NO Alcohol- NO
Therapeutic drugs- NO Therapeutic drugs- YES Zinc Sulfate 2mg,
Allergies- NO Amilecin 105 mg , IVF D5IMB 24 cc/hr,
Famotidine 7mg, Paracetamol 150 mg,
Domperdone
Allergies- NO

!!. Nutritional Metabolic Pattern

Before Hospitalization During Hospitalization
Special diet- NO Special- NO
Dietary supplements/vitamins- NO Dietary supplements/vitamins- NO
Appetite- Decreased Appetite- Normal
Swallowing- With Difficulty Swallowing- Normal
Dentres- None Dentres- None

III. Elimination Patterns

Before Hospitalization During Hospitalization
Bowel Habits- Normal Bowel Habits- Normal
Bladder Habits- Normal Bladder Habits- Normal
Incontinence- NO, Pedia Incontinence-NO, Pedia
Catheterization- None Catheterization- None

IV. Activity and Exercise

Before Hospitalization
Self care ability Independent Assistive Assistance Assistance Dependent/una Remarks
device from other from person ble
and equipment
eating/drinking X
bathing X
Dressing/groom X
ing
Toileting X
Bed making X
Transfering X
Ambulating X
Star climbing X
shopping X
cooking X
Home X
 maintenance

Assistive Devices- None

During Hospitalization
Self care ability Independent Assistive Assistance Assistance Dependent/una Remarks
device from other from person ble
and equipment
eating/drinking X
bathing X
Dressing/groom X
ing
Toileting X
Bed making X
Transfering X
Ambulating X
Star climbing X
shopping X
cooking X
Home X
maintenance

Assistive Devices- None

V. Sleep/Rest Pattern
Before Hospitalization During Hospitalization
Sleep Habits- Irregular Sleep Habits-Regular
Problems- Insomnia Problems-None

VI. Cognitive Perceptual Pattern

Before Hospitalization After Hospitalization
Mental -Alert Orientated Mental -Alert Orientated
Speech-Normal Speech-Normal
Level of anxiety-None Level of anxiety-None
Hearing-None Hearing-None
Vision-Normal Vision-Normal
Discomfort/pain-Acute Discomfort/pain-Acute

VII. Role - relationship Patterns

Before Hospitalization After Hospitalization
Marital Status-Single Marital Status-Single
Employment-Unemployed Employment-Unemployed
Support System-Parents Support System-Parents

VIII. Secuality - reproductive pattern

Before Hospitalization After Hospitalization
 Marital Status-Single Marital Status-Single
Employment-Unemployed Employment-Unemployed
Support System-Parents Support System-Parents

IX. Coping - stress tolerance/ self perception/ self concept

Before Hospitalization After Hospitalization
Major concern regarding hospitalization of Major concern regarding hospitalization of
illness- Self care , pt is dependent on parents illness- Self care , pt is dependent on parents
and family for support and guidance and family for support and guidance
Major loss/crisis/change in past years- NO Major loss/crisis/change in past years- NO
Fear of violence- NO Fear of violence- NO
Lookout for future (rate 1 poor -10 optimistic)- Lookout for future (rate 1 poor -10 optimistic)-
10 10
Describe- N/A Describe-N/A

X. Value- Belief Pattern

Religion-Catholic Religion restriction-Unknown
Request chaplain visitation- NO

Other Info
3-3-19
Temperature - 37.9 C
RR-30
HR- 138
Weight- 13.1 KG

3-7-29
Stool + UA culture Results:
Ketones +++
Bacteria 28 (normal 0-20)
Mucous threads 33 (normal 0-1)
RBC 4.15 (normal 4.5-4.8)