Pediatric Nursing Care (Case Study)

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CASE STUDY PEDIATRIC NURSING CARE IN PATIENT WITH MEDICAL DIAGNOSIS UPPER RESPIRATORY INFECTION AND BILATERAL OTITIS MEDIA

BY: GROUP I

MIRA UTAMI NINGSIH

(130915.216)

RAGIL YUNILA AGNES ANITA P. ANSALMUS ORON WIWIN NURMALANTIKA MEI D F DAEL OLIVIA YOSEFINA A. SAKTI RAHAYU LISA HANDAYANI RUFINA HURAI FREDDI RAMANDA D. MUHAMMAD HARIYADI ILMASARI META KAMELUH I.R. RUDI HARIYONO

(130915.198) (130915.174) (130915.233) (130915.234) (130915.161) (130915.163) (130915.180) (130915.183) (130915.184) (130915.199) (130915.206) (130915.210) (130915.204) (130915.232)

FACULTY OF NURSING AIRLANGGA UNIVERSITY 2009

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PREFACE We really grateful to the Most Glorious and the Most Merciful Allah SWT, we can finished this paper about Pediatric Nursing Care in Patient with Medical Diagnosis Upper Respiratory Infection and Bilateral Otitis Media ontime. This paper written as a part of process in studying English in nursing science and technology. Our appreciation to Dr. Nursalam, M. Nurs (Hons) as our lecturer who who has has gene genero rous usly ly prov provid ided ed us with with cons constr truc ucti tive ve crit critic icis ism m and and sugg sugges esti tion ons s to com complet pleted ed this this pape paper. r. Spec Specia iall than thanks ks to all all of our our colleagues in class B 12 who have participated in our seminar discussion about the case in this paper. We aware that still there are many lack in this pape paperr so we coul could d use use some some dire direct ction ion and and we alwa always ys open open to your your suggestion to make it better. At last, we hope this paper may brings much advantages to all of us.

Surabaya, 9th October 2009

Author















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CONTENTS

Cover.........................................................................................................i Preface.....................................................................................................ii Contents..................................................................................................iii I.

Case .................................................................................................1

II.

Pediatric Nursing Care in Patient with Medical Diagnosis Upper Respiratory Infection and Bilateral Otitis Media................................2 A.

Assessment.................................................................................2

B.

Data Analysis and Nursing Diagnosis.........................................5

C.

Nursing Care Plan.......................................................................8

D.

Implementation..........................................................................18

E.

Evaluation .................................................................................26















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I CASE STUDY

Mrs. King brings 2,5 years-old Billy to the pediatrician’s office becau because se he has been been “irrita “irritable ble and feveris feverish h since since last last night. night.”” Furthe Further r history reveals that Billy also had a runny nose and cough for two days, and that his appetite and fluid intake have decreased since the fever starte started. d. Billy Billy is otherw otherwise ise healthy healthy,, this is the first first episo episodic dic illness illness.. His physi physica call exami examinat nation ion reveal reveals s slight slight,, irritab irritable, le, 2,5 years-o years-old ld boy, boy, crying crying,, pulling at ears, temperature of 102 0 F, pulse 100x/minute, respiration rate 35x/minute, nasal congestion with clear discharge, tympanic membranes red and bulging bilaterally, pharynx slightly red without exudates, difficulty vocalizing. Chest clear, abdomen soft without hepatosplenomegali (HSM) and no meningeal sign. The Pediatrician diagnoses an upper respiratory infection (URI) and bilateral otitis media (BOM) and order amoxicillin 250 mg t.d.s for 10 days. You the office nurse, are to perform the parent teaching for Billy’s home care. During your discussion with Mrs. King she tells you that she is concerned that Billy is jealous of his new baby sister because he has occasional tantrums when she holds the baby. She is concerned about Billy development because he recently started to refuse using potty, a skill that is newly acquired. Mrs. King is very attentive to both new baby and Billy throughout the interview, and she asks you for suggestions in how to help Billy cope to the new arrival. While doing so, she points out that her husband has been extra attentive to Billy since his sister was born.















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II PEDIATRIC NURSING CARE IN PATIENT WITH MEDICAL DIAGNOSIS UPPER RESPIRATORY INFECTION AND BILATERAL OTITIS MEDIA

A. ASSE ASSESS SSME MENT NT 1. Pati Patien entt Iden Identi tity ty Name

: “B”

Age

: 2,5 years old

Race

: Java

Religion

: Moslem

Education

:-

Address

: Mulyorejo, Surabaya

2. Histor History y Of Of Pre Presen sentt Illne Illness ss –

Chief Complain Complain : Feverish Feverish since last night Pres Presen entt Illn Illnes ess s

–

: Clie Client nt has has been been irrit irritab able le and and feve feveri rish sh sinc since e

last night, he also had a runny nose and cough for two days. 1. Past Past Nur Nursi sing ng Hist Histor ory y

1.

–

History of contagious diseases

: None

–

Hereditary Diseases

:None

–

Allergic history

: None

Family Health History Client’s mother said that their family doesn’t have history of contagious diseases and hereditary diseases

2. Observ Observati ation on and Physic Physical al Examina Examinatio tion n















6

–

BI: BREATHING ( Respiratory System) Complain

: Cough (+), Breathing (-), difficulty vocalizing

RR patter pattern n : Freque Frequency ncy 30 x/mn x/mnt, t, Rhyt Rhythm hm : Regula Regular r Breath Breathing ing

: whee wheezin zing g (-), (-), ronchi ronchi (-), secret secret (+), flares flares nose nose (+), hyperemi Faring (+) no exudates, runny nose (+)

Problem –

: Ineffective Airway Clearance

B2: BLEEDING (Cardiovascular System) Comp Compla lain in

: che chest st pain pain (-), (-), P = 135 135 tim times es/m /min inut ute e

Hear Heartt soun sound d : Norm Normal al Problem –

: None

B3: BRAIN (Nervous System) Orie Orient ntat atio ion n

: Pers Person on,, Time Time,, Plac Place e norm normal al

Meningeal sign (-) Awar Awaren enes ess s

: Comp Compos osm menti entis s

GCS

: E4 V5 M 6

Eye

: Pupil Isochors, Light reflex (+)

Conj Conjun unct ctiv iva a : Ligh Lightt red red

–

Problem

: None

Ea r

: Tympani membranes red, bulging bilaterally

Problem

: Acute Pain

B4: BLADDER (Genitourinary System) Complain

: None

Nocturia

: (-)

Fluid Fluid intake intake : Oral Oral 1000cc 1000cc/da /day, y, Parent Parentera erall Problem –

: 750 750 cc/day cc/day

: None

B5: BOWEL (Gastrointestinal System) Mouth

: Pharynx slightly red, Stomatitis(+)

Complain

: Abdomen(-),Alvi elimination(-).

Weight

: 13 kg

High : 100 cm

















7

Problem –

–

: Altered nutrition; less than body requirement

B6: BONE (Bone – Muscle – Integument) Joint Activity

: Free

Back Injury

: None,

Integuments

: Skin feels hot, T: 38,80C

Acral

: Warm

Turgor

: Excellent

Problem

: Hyperthermia

Psycho-social Client’s mother said that he is jealous of his new baby sister because he has occasional tantrums when she holds the baby. Client’s mother is concerned about client’s development because he recently started to refuse using potty, a skill that is newly acquired. Client crying and seems irritable.

–

Endocrine System Compla Complain in : None None

1. Labo Labora rato tori rium um Blood Hb

: 11,9

•

PLT

: 160

•

WBC

: 13,2

•

RBC

: 3,00

•

















8

Paracetamol 250mg t.d.s

•

A. DATA DATA ANAL ANALYS YSIS IS DATA

ETIOLOGY

Subjective Data

Increase metabolism

Clie Client nt’s ’s

moth mother er

said said that that he has has been

irritable

and

feverish

since last night. Objective Data Temperature of 1020 F Tympanic memb membra rane nes s and

red red

bulging

bilaterally Pharyn Pharynx x

slight slightly ly

red

without

exudates Lab Lab test test WBC WBC :

secondary to disease/ infection process

PROBLEMS

Hypertermia

















9

since last night Objective

press the tympanic


seem seems s

membrane

irri-table, crying Pulling at ears

tympanic membrane

tympanic memb membra rane nes s and

red red

bulging

bilaterally

Pain

Subjective:

Less appetite and

Clie Client nt’s ’s said

bulging bilaterally

moth mother er

that

his

appetite and fluid intake

have

decr decrea ease se

sinc since e

the fever started. Clie Client nt’s ’s

moth mother er

said that he only finished a half of his meals

Alte Altere red d nutri nutritio tion: n: Risk Risk

increased metabolism

fo r

secondary to disease

requirements

process

less

than

body

















10


moth mother er edem edema a of of nas nasal al muc mucou ous s

clea cleara ranc nce e

said said that that he had had runn runny y nose nose and and cough two days. Objective Nasal congestion with

clear

discharge The client’s can’t perform effective cough Difficulty vocalizing

Subjective Data Clie Client nt’s ’s

Sibl Siblin ing g moth mother er

said that Billy is jealous

of

his

new new baby baby sist sister er becaus because e he has occasional

com complex plex;;

new arrival in family

The The Family coping: risk for growth

















11

A. NURS NURSIN ING G DIAGNO DIAGNOST STIC IC 1.

Ineffective airway clearance related to retained secret and edema of nasal mucous, signed by client’s mother said that he had runny nose and cough two days, nasal congestion with clear discharge, client can’t perform effective cough, difficulty vocalizing

2.

Acute pain related to increasin increasing g of tension in middle middle ear secondary secondary to infection process signed by client’s mother said that Billy has been irritable and feverish since last night, client’s mother said that his appe appeti tite te has has decr decrea ease se,, clie client nt seem seems s irrit irritab able le,, pulli pulling ng at ears ears,, tympanic membranes red and bulging bilaterally

3.

Hyperthermia related to Increase metabolism secondary to disease/ infection infection process signed signed by Client’s mother said that he has been irrit irritab able le and and feve feveris rish h sinc since e last last nigh night, t, temp temper erat atur ure e of 102 1020 F, tympanic membranes red and bulging bilaterally, pharynx slightly red without exudates.

4.

Altere Altered d nutriti nutrition: on: Risk Risk for less less than than body body require requireme ment nt relate related d to decreased decreased appetite and the increased increased metabolism metabolism secondary secondary to disease process signed by client’s mother said that his appetite and fluid intake have decrease since the fever started, client’s mother said that he only finished a half of his meals, pharynx slightly red without exudates

5.

Family coping: risk for growth related to sibling complex; the new arrival in family signed by client’s mother said that Billy is jealous of his new baby sister because he has occasional tantrums when she holds the baby, client’s mother said that Billy recently refuse using



















12

1

adequate air

respiratory

exchange, as

status;

evidence by:

depth

a.

Use

pres presen entt

to some some degr degree ee and

may

be

pronounced

correct

during respiratory

breathing/co

stress.

technique

2. Monitoring ing

vital

2. Ina Inadequ dequa ate oxygenation

sign

cause cause increa increased sed pulse rate.

Productive cough

3.

Evaluate amount and

c.

rate,

of

ughing

b.

usua usually lly

type

Client’s and

secre-tions

care giver

being pro-duce

make it difficult to maintain effective airways 4.

understand

client to

sticky mucus can

of

know and

how to help

3. Exce Excess ssiv ive e and/o and/or r

4.

Assess Assess

client client’s/ ’s/

careg caregive iverr knowknow-

To

determine

aduca-tional needs

















13

at-rest

or

compromised indi indivi vidu dual al,, 6.

inform inform client client or

as one with sleep

care

apnea

giver

to

maintain ade adequate uate

7.

such such

6. Cold flu fluid

flui fluid d

water

or

can lowe lower r

intake especially

the verge limit of

warm fluid.

allergic

Administer

make

prescribed

congestion worse

and nasal

expectorant, decongest decongestant ant or anti histamine

7.

Expectorant helps

loosen

secretions

so

they

be

can

coug oughed hed up an wxpelled. Decongestant

















14

dosage)

increase client/care-giver discip disciplin line, e,

avoid avoid

anxiety related to side

effect

of

medicine als also the the

and

dete etermin rmine e succ uccess ess

of

therapy 2

Demonstrate a

1. Note

client’s

1. affe affect ctin ing g abil ability ity to

decrease in

age/

report

symptoms/

developmental

parameters

complaints as note

level

in defining

current

characteristic

condition condition (e.g.,

a. Dem Demons onstrat trat

infant/child,

e of relaxation

and

critically ill) 2.

Obtain Obtain client client’s ’s

2.

identify

pain

















15

(e.g., inflammation, trauma,

scale

infection

helps

to

plan the suitable

process) 4.

4. asse assess ssme ment nt pai pain n

Use pain rating scale

way

to

relieve

pain

appropriat appropriate e for age/ age/ cogniti cognition on (e.g.,

facial

expression/Wo ng-Baker faces pain pain scale scale for for pediatric

or

nonverbal, beha behavi vior or scale) 5. Observe nonverbal

pain pain

5. iden identi tify fy beha behavi vior ors s that may indicate pain pain in pers person ons s who

cannot

















16

on the type and 7.

severi severity ty of pain. pain.

Administer analgesic

Knowledge

to

medication

maximal dosage

procedure

as

incr increa ease se

“acceptable” lev level

of

and

caregiver about

the

medication

to

note note the the cues cues of pain and to manage

8.

For

clie lient

who

cannot verbal verbalizi izing ng pain, pain, caregiver

shou should ld note note the the

Teach caregiver

in

therapy.

the

procedure 8.

cooperation

inform or

clie client nt//

caregiver

pain

client

of

cues ues of pain ain to start

manage

comfort to reduce pain pain and help helps s client to maintain



















17

pressure in ear (e.g., (e.g., promot promote e swal swallo lowi wing ng

or

yawning) 3

Temperature in in

1. Note

1.

Infants,

young

normal range as

chronological

chil-dren

evidence by:

and

elde elderly rly

developmental

are

age of client

susceptible

a. Maintain core

and pers person ons s most

temperature

dama-ging

within

hyperthermia.

normal

Environmental

to

















18

enhances 3.

Teac each

pare paren nts

how to measure child’s temp temper erat atur ure, e, what

body

tempetempe-rat rature ure give give

at

to

anti antipy pyre reti tic c

medica-tions, and

what

symptoms

to

report

to

immu immune ne

syst system em

functioning

in

presence

of

infe infect ctio ion n and and is not

harmf rmful

as

long as individual is not dehydrated or susceptible to febrile febrile

seizu seizures res..

Fever

may

be

trea treate ted d at home home

















19

4.

Discuss

tion

importance ade adequate uate intake

respiration and to

of flu fluid

at

and

avoid dehydration

all

times times and ways ways to

improve

hydrat hydration ion status status when ill or when under

stress

(e.g (e.g., .,

exer exerci cise se,,

5.

Heat injuries can be

imme immedi diat atel ely y

hot

life-threatening.

environment).

Bein Being g awar aware e of

















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a. Limiting

a. Encourage

heat

clothing/dr clothing/dress ess in

loss loss by radiat radiation ion

lightweight,

and conduction

loose-fitting clothes. b.

Cool

the

environ-ment with

air

cond conditi ition onin ing g

or

fans c.

Provide cool/tepid

b. Promotes loss convection

heat by

















21

and linens dry 1.

d. To

Administer medica-tions (e.g.,

reduce

shivering 1.

dantro-

To

manage

hyper-thermia,

lene,

contro controll shiver shivering ing

chlorproma-zine,

and seizures.

or diazepam) as ordered

4

Demonstrate derstanding

unin

avoid altered nutri-

1.

Assess client/care-

1.

Identifies teaching

needs



















22

ings ings,, as indi indica ca--

chances

ted; suppleme supplement nt

increasing

with

amou amount nt of nutr nutrii-

easily

gested snack

d i-

of the

ents ents take taken n over over 24-hour period c. Enhance

food

















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possible 2.

with withhe held ld

Suggest

meals

client/caregiver

to

promote adequate/timel

befo before re or

meals inte interf rfer erin ing g food intake

with if with with

















24

taking care of the new baby help client to find his 4. Sugge Suggest st famil family y to

new role in

give the same

family as a

attention and care

brother and also

















25

1.

Ineffective

1. Monit onito orin ring

air-way

respiratory

clearance

status;

related to re-

depth

tained tained secret secret d

d

1.

rate,

Res Respira pirati tio on 35x/ Difficulty

rate rate minute. in

respiration beca becaus use e of nasa nasall

















26

5.

informing

underst rstand

client/care-giver

will

to

suggestion

positioning

client’s appro appro-p -pria riate te age

and

follow

the

head for for and

6. Client’s

parents



















27

















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Pediatric Nursing Care (Case Study)

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