NURSING CARE PLAN

1. Patient’s Profile

Full Name: Eustaquio, Jahzeel Luz Nickname: Jahzeel

Gender: Female Age: 2 years old
Birth date: April 3, 2007
Birth place: Sto. Niño Hospital (Baguio City)
Father: Joseph Eustaquio occupation: Mechanic
Mother: Lucia Eustaquio occupation: housekeeper,
vendor
Address: IC 64 Belag, La Trinidad, Benguet
Civil Status: Single Religion: Pentecost
Nationality: Filipino Occupation: N/A
INFORMANT: Lucia Eustaquio

2. Health History

a. Chief Complaint
The mother of Jahzeel brought her to the Saint Louis- Hospital of the
Sacred Heart due
to severe vomiting and fever since March 4, 2010.

b. History of Present Illness

According to the informant (Mrs.Lucia Eustaquio- mother of Jahzeel),
her child had vomit for 6
times and had suffered from intermittent fever. Jahzeel’s(client) vomit is
colored yellow to white. The mother is suspecting that the case of her child
vomiting and having fever is due to her inflamed tonsils. According to the
mother, no suspicious food which may trigger Jahzeel’s urged to vomit. She
even said that she(Jahzeel) has not ingested anything that she is allergic to.
Paracetamol was given to the child, prior to her admission, so as to decrease
her body temperature.

c. Past Medical History

No previous hospitalization of the child. The significant others claimed
no known allergies. There is also no history of chickenpox, measles, mumps,
no accidents, injuries, trauma and no operation done to the patient.
d. Family History
The patient is the first child and is the only child as of now. Parents
claimed that they had no family history of Bronchial Asthma, Diabetes
Mellitus, Arthritis, Cardiovascular Disease and Congenital Anomalies or
Abnormalities.

e. Environmental History
The child lives with her parents in a non-congested neighborhood in an
owned house with two (2) rooms and three (3) occupants at IC 64 Belag, La
Trinidad, Benguet. Source of water for domestic purposes comes from the
Baguio Water District while for drinking, mineral water is bought. Toilet is
found in the house and is water flush type. Garbage is collected regularly
every week. The significant others claimed presence of fireflies and
mosquitoes in the environment. They speak kankana-ey, Ilocano, Filipino and
English. The father is thirty-five (35) years old and a college undergraduate
at 3rd year college of Mechanical Engineering and currently working as
Mechanic and acts as the primary care giver of the family. The mother is
thirty-six (36), graduate of Midwifery and is currently working as a vendor in
their family business. In terms of problem they asked guidance from friends
in their church, their parents and close relatives.

1. Gordon’s Functional Patterns

• Health Perception- Health Management Pattern

• Health is perceived as

• Nutritional- Metabolic Pattern

• The mother decides what the child will eat
• No known food allergies
• The child is not choosy in terms of food

• Elimination Pattern
• The significant other claimed no problem in voiding and defecating.
• Usually void five to seven times a day and higher volume in the morning
which is the first daily urine. Color is pale yellow and is aromatic.
• Defecate once daily with usually semi formed stool.

• Activity- Exercise Pattern

• The patient plays with the mother and other relatives.
• The patient is able to crawl and sit alone and unable to stand.
• The mother allows the child watch television and hear music.
• The mother usually let the child take a nap in the afternoon.
• The child is trying to learn how to write the alphabet
 • The child’s usual past time is playing with their neighbor

• Sleep- Rest Pattern

• Usual hour of sleep is 8 to 9 hours; usual time of sleep is 9 pm and awakes
usually at 5 am or 6 am.
• At daytime she sleeps 2 to 3 hours.

• Cognitive- Perceptual Pattern

• The child is able to play with the student nurse.
• Sometimes irritable.

• Self Perception
• Role- Relationship Pattern
• The patient is the only child in the family

• Sexuality Reproductive
• The patient is a female. 7 years old thus unable to procreate.

• Coping- Stress Tolerance Pattern

• The patient is irritable.
• Crying

• Value- Belief Pattern

• The family together with Jahzeel does not usually attend in their church
• The client is practicing their religion- pentecost

1. Diagnostic Results
Routine Blood Count
WBC 22.8 4.8-10.0 x 109 g/l

lymphocytes 2.6 0.6-3.5 x 109 g/l

Mid number 1.0 0.1-0.9 x 109 g/l

Granulocyte number 19.2 1.3-6.7 x 10 9

g/l

Lymphocyte Percentage 11.4 14.0-53.0

Mid Percent 4.4 3.0- 16.0

Granulocyte
84.2 30-90
Percentage

RBC 4.69 3.8-6.5 x 12

g/l
>> Blood tests are used to determine physiological and biochemical states,
such as disease, mineral content, drug effectiveness, and organ function.
Although the term blood test is used, most routine tests (except for most
haematology) are done on plasma or serum, instead of blood cells.]

>> Since the mid number, granulocyte number and lymphocyte percentage
is elevated, the child is suspected suffering from school

Throat Swab
few gram (+) cocci in singles, in pairs, in short chains and in small clusters
few epithelial cells and occasional cell pus noted

>>This test states that the client is positive in cocci species then the child is
positive for infection
>> A throat swab culture is a laboratory test done to isolate and identify
organisms that may cause infection in the throat

Parasitology
Negative
(-)
>>refers to a series of laboratory tests done on fecal sample to analyze the
condition of a person’s digestive tract
>>Since the client’s findings are negative, there is no problem in the child’s
digestive system

Drug Study

Generic name Paracetamol

Brand name Tempra® [Forte syr]

Drug classification Analgesics (Non-Opioid) &
Antipyretics

MOA: Tempra is acetaminophen

(paracetamol), a safe and effective
analgesic-antipyretic. It is a not
salicylate. It contains no phenacetin
or caffeine. It has no effect on
prothrombin time. Tempra is
particularly valuable for use in
patients who do not tolerate aspirin
 well because it is less likely to cause
GI distress.

Indications: for reducing fever and for the

temporary relief of minor aches,
pains and discomfort associated with
the common colds or flu, inoculations
or vaccinations. It is also valuable in
reducing pain following tonsillectomy
and adenoidectomy.

Contraindications: Patients with a known

hypersensitivity to acetaminophen
(paracetamol). Long-term use of
acetaminophen (paracetamol) in
patients with anemia or with cardiac,
pulmonary, renal and/or hepatic
disease.

Adverse effect: Generally, side effects to

acetaminophen (paracetamol) are
mild, though hematological reactions
have been reported. Skin rashes and
other allergic reactions occur
occasionally.

Nursing Considerations >monitor the client for any adversed

reaction
>check the medication administered
and the right dose
>teach the client and her significant
others on the action of the medicine
given
>check whether the client is allergic
to paracetamol, if so, speak to the
client’s physician about this

Generic name brompheniramine maleate +

phenylpropanolamine hydrochloride

Brand name Pediatapp syrup

Drug classification Antihistamines & Antiallergics Cough
& Cold Preparations

MOA: Relieves nasal congestion and allergy

Indications: Treatment of nasal congestion.

Symptomatic relief of allergic
conditions, mainly rhinitis &
conjunctivitis.

Special Precaution: HTN, toxic goiter, benign prostatic

hyperplasia, irregular heart rate,
glaucoma, CV disorder, diabetes
mellitus, hyperthyroidism, urinary
retention, pyloroduodenal
obstruction.

Adverse effect: CNS depression including slight

drowsiness to deep sleep, lassitude,
dizziness, incoordination. Headache,
psychomotor impairment and
antimuscarinic effects. Rarely, rashes
and hypersensitivity reactions; blood
disorders, convulsions, sweating,
myalgia, extrapyramidal effects,
tremor, confusion, tinnitus,
hypotension, hair loss.
Potentially Fatal: Palpitations,
arrhythmias, blood disorders, and
liver dysfunction may occur

Nursing Considerations >Check for allergic reactions

>monitor the patient for any adverse
effect
>Assess if the client is suffering from
DM, epilepsy, glaucoma, heart or
blood vessel disease, hiatal hernia,
high blodd pressure, myasthenia
gravis, obstructed bladder or
intestinal tract, peptic ulcer, enlarged
prostate gland, or thyroid disease
>if any of the above mentioned
 diseases is present, tell the physician
about this
>Advise the client to drink at least
eight glasses of water
>Advise the client to avoid excessive
work and exercise in hot weather

Generic name buclizine hydrochloride + lysine

hydrochloride

Brand name Appebon 500 Syrup

Drug classification Appetite enhancer

MOA: Increases appetite

Indications: Poor appetite, underwt, anorexia

nervosa. For nutritional support in
post-op cases, metabolic disorders &
convalescence.

Contraindications: Angle closure glaucoma, prostate

hypertrophy & primary
hemachromatosis.

Adverse effect: Drowsiness & dulling of mental

alertness, dry mouth, headache,
nausea, jitteriness, tiredness.

Nursing Considerations >Advise the patient to have ample

rest periods
>Tell the client and her significant
others not to walk alone to avoid any
accidents due to drowsiness
> observe the 10 rights in drug
administration
>Increase fluid intake to at least 8
glasses a day

2. List of Prioritized Nursing Diagnosis

➢ Hyperthermia related to increased metabolic rate
  When we say hyperthermia the body temperature is elevated in such
a way so as to kill the invading component from entering totally our
system. Since there and then, the child’s temperature is above normal
at the level of 39.1°C.

➢ Nutrition imbalanced less than body requirements related to nausea and vomiting.
 Nausea and vomiting are not diseases, but rather are symptoms of many different
conditions, such as infection ("stomach flu"), food poisoning, motion sickness,
overeating, blocked intestine, illness, concussion or brain injury, appendicitis, and
migraines. The client’s intake of nutrients is not sufficient due to nausea and vomiting.
Everytime the client ingests something, the food (most of the time) is take out. Since that
is the case the mother of the client gives foods that the child can ingest like crackers.
Since crackers is most of the time given so as to sustain her need.

1. Pathophysiology
bacteria

palatine tonsil

invasion of bacteria

inflammatory process

sore throat, with fever, headache, general aching, and congestion and
smelling of the palatine tonsils bilaterally, and body malaise

2. NCP Proper

a. Subjective and Objective Data

S: > “Nilalagnat siya,” the mother verbalized
O: > fully awake and conscious
>flushed skin, warm to touch
>(-) Difficulty of breathing
>child is irritable
>hugged by the mother
>cries when significant others come
>sweat noted
>RR: 26 cycles per minute; T°: 39.1; CR: 142 beats per minute

b. Goals (STO and LTO)

STO
>Within 3 hours of nursing intervention, the clients temperature will
decrease from 39.1 to 37.5
 LTO
>Within 2 days of nursing intervention/s, the client will not suffer from
hyperthermia at the moment

c. Explanation of the Problem

When we say hyperthermia the body temperature is elevated in such a
way so as to kill the invading component from entering totally our system.
Since there and then, the child’s temperature is above normal at the level
of 39.1°C.

d. Other Part/s:
Nursing Diagnosis: Hyperthermia related to increased metabolic rate

Criteria for
Intervention Rationale Evaluation
Evaluation

Dx> Assess
underlying ➢ to control
factors cause of factors that
fever triggers
fever
➢ Assess vital
➢ to monitor
signs
if the
➢ Review
temperatur
signs and
e is
symptoms
improving
of
or not
hypertherm
➢ to monitor
ia
➢ monitor input and
I&O output
➢

a. Subjective and Objective Data

 b. Goals (STO and LTO)
c. Explanation of the Problem
d. Other Part/s:
e. Nursing Diagnosis:

Criteria for
Intervention Rationale Evaluation
Evaluation

1. Reference
>Nurse’s Pocket Guide by Doenges, Moorhouse and Murr
>http://www.babycenter.com.au/pregnancy/antenatalhealth/testsandcare/bl
oodtests/#ixzz0hqfwu99k
>http://www.mims.com/Page.aspx?
menuid=mng&name=Appebon+Kid+Syrup+syr&h=appebon,kid,syrup,syr&
CTRY=PH&searchstring=Appebon+Kid+Syrup+syr
> Brunner and Suddhart’s Med-Surg Nursing by Smeltzer, Bare, Hinkle and
Cheever
>Fundamentals of Nursing Practive by Potter and Perry
>>Fundamentals of Nursing Practive by Kozier
>>Prescription Drugs by the Editors of Consumer Guide