S.No. Nursing assessment 1.

Patient is on mechanical ventilation, no self respiratory effort On SIMV mode , PEEP - 8 cm H2O,PIP- 24cm H2O , I:E- 1:2 RR:46/min

Nursing Dx.

Expected outcome Planning

Nursing Interventions Implementations

evaluation

Altered breathing pattern R/T disease condition

Patient will have clear airway

Assess the respiratory status

Respiratory status assessed Maintains clear airway & demonstrates

Provide proper positioning

Prone position given

appropriate breath sounds

Perform suctioning

Before & after suctioning preoxygenate with 100% oxygen. Oral & ET

Perform chest physiotherapy

suctioning done.

Chest physiotherapy done during suctioning

S.No. Nursing assessment 2. Bed sore present on right pinna of ear

Nursing Dx.

Expected outcome Planning

Nursing Interventions Implementations Condition of the skin assessed

Evaluation

Risk for impaired skin integrity R/T immobility

Patient will have healing bed sore No redness at bony

Assess the skin condition

Maintain normal skin integrity

Frequent position changing

Change the position of patient every 2 hourly.

prominence Provide comfort measures

Cotton rings, shoulder support, gloves filled with water provided

Dressing of bed sore

Bed sore dressing done with betdine followed by Neosporin

S.No. Nursing assessment 3. Absent corneal reflex, debris present on eye

Nursing Dx.

Expected outcome Planning

Nursing Interventions Implementations The condition of eyes asssessd

evaluation

Impaired tissue integrity of cornea R/T to diminished or absent corneal reflex

Patient will have no corneal abrasion and redness

Assess the condition of eyes

Has no corneal irritation

Cleanse the eyes Administer artificial tears

Eyes are cleansed with cotton balls moistened with normal saline

Lacrigel ointment instilled as prescribed

Cover eye with eye patches

Eye patches are used to cover eyes

S.No. Nursing assessment 4. Child exhibits frequent changes in body temperature

Nursing Dx.

Expected outcome Planning

Nursing Interventions Implementations Vital sign assessed T37C P-112/min R30/min Assess childs

evaluation

Potential alteration in body temperature R/T fluid volume deficit / IV administration / unknown reason

Body

Attainment of normal body temperature

temperature physiologic status remains in normal range Provide stable environment temperature

Stable environmental temp provided

Provide app.clothing Administer extra fluids

Appropriate clothing provided.

Teaching parents regarding temp & environment

Extra fluids administered with temp elevation.

S.No. Nursing assessment 5. Parental anxiety

Nursing Dx.

Expected outcome Planning

Nursing Interventions Implementations Assessed the level of parental anxiety

evaluation

Interrupted family processes R/T the childs life threatening

Family will receive adequate support

To assess the level of parental anxiety

Parents could ventilate their anxiety

To clarify the doubts of the parents

Clarified the doubts of the parents

To involve the parents in the care of the child

Involved the parents in the care of the child

To teach the parents the importance of adherence to the treatment regimen

Taught the parents the importance of adherence to the treatment regimen