GNRS 583 Care plan

1 Copied with permission: KeithRN.com 1
Pediatric Nursing Care Plan
Azusa Pacific University
School of Nursing ELM Program
Student Name: Dana Messmore
Pt. initial, gender & age: K.P. age: 14 months
Height/Percentile: 80 cm/ 31.5 in: 89% Weight/Percentile: 9.22 kg/ 50%
OFC/Percentile: 50.5 cm/ 19.88in, 99.99%
Admit Date: 8/7/2016
Admitting diagnosis: Rectal Bleeding, Anemia
Date of Care: 8/8/2016
ASSESSMENT DATA:
1. History of Present Problem:
Patient is a 14-month old female with colonic polyposis, rectal bleeding, anemia,
dependence on blood transfusions and albumin infusions; she is now admitted for repeat
colonoscopy and possible blood transfusion. Patient was just admitted and discharged at the end
of July. Since then has been afebrile. Patient has continued to have bloody stools, which parents
partially attribute to the heparin required to flush her PICC line.
2. Pass Medical History:
The patient was diagnosed with macrocephaly in July of last year. She was found to have
rectal bleeding, colon polyps, anemia, and Hypoalbuminemia in April of this year. She was also
found to be positive for rotavirus enteritis in April of this year. Other than these the patient does
not have a past medical history.
What is the relationship of your patient’s past medical history (PMH) and current
medication? Which medications treat which conditions?
PMH Home Medications Pharm. Classification Expected Outcome
1.anemia
2.hypoalbuminemia
3. Colon Polyps
1.Receives RBC
transfusions regularly
2.Has to come in to
POU to receive
albumin transfusions
twice per week
3. Receives RBC
transfusion in order to
make up for blood
loss from polyps
1. blood products
2.protein
3. blood products
1. Patients hemoglobin
levels will increase.
2. Patients albumin levels
will rise.
3. Will prevent
hemoglobin levels from
dropping lower due to
bleeding.
Patient Care Begins:
Vital Signs:
Time Temp F/C Pulse
(apical/radial)
Resp/min BP in mmHg
Right or Left
Pulse Ox % Room
air/oxygen & delivery

0348 98.3 F 133 24 116/87 left leg 100 RA
0800 97.3 F 135 24 92/51 left leg 99 RA
1154 98.7 F 159 24 95/44 left leg 99 RA
1700 97.0 F 133 44 92/46 left leg 97 at 3 L
Pain Assessment:
Time Pain Tool
Used:
Numeric,
FLACC
Baker/Wong
Pain
Rating
0-10
Pain Description
(OLDCART)
Onset, Location, Duration,
Characteristic,
Aggravating, Relieving,
Treatment
Functional
Pain Goal
0-10
Pain
Medication (or
other care)
Include name, dose,
route, & frequency
Response To
Intervention
0348 FLACC 0 NA 2 NA NA
What vital sign data are relevant that must be recognized as clinically significant?
Relevant Vital Sign Data: Clinical Significance:
1. Temperature
2. Blood pressure
3. Heart Rate
1. Patient received transfusion of RBCs the night
before and so should be watched for fever.
2. Patient is having issues with bleeding and so
should be watched for a drop in blood pressure to
indicate more blood loss.
3. Heart rate can also show shock if there is too
much blood loss.
Physical Assessment on day of care:
General Appearance: Alert, irritated, restless; Macrocephalic, atraumatic, anterior fontanel widely
open and soft, PERRLA,sclera WNL
Neuro: Alert, appropriately interactive, moving all extremities equally, 5/5 strength,
tone WNL.
Cardio-Vascular: (Radial/Femoral/Pedal): strong and equal bilaterally; No murmurs, NSR, Heart
rate elevated during crying episodes.

Respiratory: Clear to auscultation, breathing comfortably with no distress noted. No
adventitious sounds noted.
GI: Clear to auscultation, breathing comfortably with no distress noted. No
adventitious sounds noted. Bloody stools noted.
GU: Urine is amber colored but clear. Amount is adequate for child’s size.
Skin: Skin warm,dry, and appropriate for ethnicity (Caucasian). Diaper rash
apparent. No redness or swelling noted around PICC insertion site
Musculo-Skeletal: Extremities Warm, well perfused, normal joints and range of motion.
Fluids /Nutrition
Diet / Feeding method
Patient is NPO because she is receiving colonoscopy
today
GT feeds:
NA
IV solution /rate:
D 5 ½ with 20 meq K going at 40 mL/hr
IV site/type:
PICC line,left brachial
24 hour fluid calculation:
Maintenance:
(9.22 x 100) = 920 ml/day or 38 ml/hr
1 ½ times maintenance:
1,380 ml/day or 57.5 ml/hr
24 HOUR INTAKE: Total ____1460___________
Oral _500_____ Enteral 0_____ IV ______960____
24 HOUR OUTPUT: Total ___1100__________
Void ___700____ Stool _400____ Emesis __0______
Growth and Development: (Erikson Piaget, Physical)
Actual Developmental level: Provide specific
examples/criteria for your assessment.
Patient shows signs of developmental delay,
only says 1 syllable words such as ma. Does
not crawl and has not tried to walk at all.
Patient struggles with trust issues and will only
let mom touch her, and sometimes dad.
Psychosocial: trust vs. mistrust
Psychosexual: oral stage
Cognitive: sensory motor
Moral: Preconventional
Spiritual: stage 0, undifferentiated
Expected developmental level:
At this age patient should be speaking with two
syllable words at least and should be able to
piece together a few short words. Should also
crawl and be attempting to stand and walk.
Psychosocial: autonomy versus shame and doubt
Psychosexual: oral stage
Cognitive: sensory motor
Moral: Preconventional
Spiritual: stage 0, undifferentiated
Play needs: (What did you actually do?)
Patient refused to be separated from mother so
I just talked to her and played her a DVD
Family involvement:
Both mother and father in the room at all
times. Mother heavily involved in patient’s
care.
Spiritual needs:
Patient needs a familiar figure for support and
care. Needs to be able to trust said person.
-Parents are in need of someone to talk to and
just listen about everything they have going on.

What body system(s) will you most thoroughly assess based on the primary/priority concern?
RELEVANT Assessment Data: Clinical Significance:
Will Assess GI and cardiovascular
GI: bloody stools
Cardiovascular: both HR and BP
within normal limits
-mean the patient still has active bleeding thought to be
from colon polyps
-Although patient is losing blood, it is not enough to
cause the patient serious effects yet.
Radiology Reports:
What diagnostic results are relevant that must be recognized as clinically significant for the
nurse?
Relevant Results: Clinical Significance:
X-ray NA
CT Scan NA
MRI/Ultrasound NA
Other: colonoscopy 16 polyps were found of various sizes, some with active bleeding.
Polyps were removed and biopsies sent to the lab for testing.
Lab Order(s) Current
values:
N/H/L Previous Results:
If applicable
Complete
Blood Count
Clinical Significance
for High or Low
results
Trends:
Stable/Improve/worse
WBC 4.5 Improving; patient
may have some sort
of infection or WBCs
are high in response
to blood transfusion.
4.7 6.9
Hgb 9.9 Improving; low due
to anemia and active
bleeding
6.9 8.4
Hct 30.1 Improving; low due
to anemia and active
bleeding
22.2 26.7
Platelets 263 Worsening 289 395
Neutrophils 37.5 NA NA NA
Basic
Metabolic
Panel
NA NA NA
Sodium 135 NA NA NA
Potassium 4.0 NA NA NA
Glucose NA NA NA NA
BUN 12 NA NA NA
Creatinine NA NA NA NA
Calcium NA NA NA NA

Chloride 105 NA NA NA
Bicarb NA NA NA NA
Other Labs: NA NA NA NA
Albumin 2.2 Albumin is low
because patient
suffers from
Hypoalbuminemia
NA NA
NA NA NA NA
What lab results are relevant that must be recognized as clinically significant to the nurse?
Relevant
Labs:
Clinical Significance: Trends: Improve/worsening/Stable
Hgb Patient has anemia and
active bleeding from colon
polyps
Improving
Hct Patient has anemia and
polyps
Improving
Plts Patient has anemia and
polyps
Worsening but still WNL
Albumin Patient suffers from
Hypoalbuminemia and
must receive biweekly
infusions
NA
Current Medications List: Create a list of medications that you GAVE DURING YOUR
SHIFT: (Reference Needed)
Name of Medication given:
Sodium phosphates enema
Dose:
0.5 bottle
(57mL)
Route:
Rectal
Frequency:
One time
Classification: Osmotic laxative
Action: Hyperosmotic effect of sodium draws excess water into colon,
promoting evacuation.
Safe dose range for age/wt: Max of ½ bottle (59mL) per 24H period.
Rationale for use in THIS
patient:
Patient will be receiving a colonoscopy later in the day and so
needs to have bowels clearing out.
Desired Effect: To promote bowel evacuation.
Side Effects: Fecal urgency, fecal incontinence, abdominal distension and
pain, nausea, anal discomfort.
Toxic Effect: Renal failure, arrhythmias, tetany, severe electrolyte imbalance.

Nursing Implications: Monitor for abdominal cramping and distension. Monitor for
fecal urgency and incontinence.
Pt./Family teaching needs: Teach patients about the side effects and the expected outcomes.
Name of Medication given:
D 5 ½ w/ 20 meq K
Dose:
1000 mL
Route:
IV; 40 mL/hr.
Frequency:
Continuous
Classification: Fluid and electrolytes
Action: Replenish the fluid and electrolyte levels.
Safe dose range for age/wt: 38.5-57.5 mL/hour (per previous maintenance dose calculation)
Rationale for use in THIS
patient:
Patient is NPO. Fluids are to prevent dehydration.
Desired Effect: Hydrate the patient and keep electrolytes WNL.
Side Effects: Hypervolemia, electrolyte imbalance
Toxic Effect: Hypervolemia
Nursing Implications: Monitor electrolyte levels. Frequently assess IV site.
Pt./Family teaching needs: Teach family signs and symptoms of fluid overload and IV
infiltration.
Clinical Reasoning Begins:
What is the primary problem that your patient is most likely presenting with?
Anemia, colon polyps
In your own words, what is the underlying cause/pathophysiology of this concern? (APA
format and MUST be referenced!)
Pathophysiology
Anemia is described as a “condition in which the number of red blood cells or the
hemoglobin concentration is reduced below the normal values for age” (Hockenberry & Wilson,
2009). The different anemias are classified based on manifestations (erythrocyte or Hgb
depletion). In this situation the patient also has rectal bleeding, which could be a possible cause
of the anemia. The patient has active bleeding polyps and has blood in her diaper every day. Her
labs show low hemoglobin and hematocrit and decreasing platelet count. The blood loss from
active bleeding causes the hemoglobin and hematocrit to drop. The exact cause of the anemia is

unknown; however, the consequences are similar in all of the anemias. The oxygen carrying
capacity of the blood decreases which causes a decreased amount of oxygen to the cells.
The rectal bleeding is caused by numerous polyps in the colon. This constant
development of polyps is believed to have led to chronic anemia because there is a constant loss
of blood and hemoglobin. The body is unable to replenish the hemoglobin at a fast enough rate
because there is constant bleeding occurring. Therefore the body is constantly low on
hemoglobin. This constant loss of blood can also lead to hypovolemia, which in turn can lead to
hypotension. This hypotension can cause a decrease in tissue perfusion because of the decreased
oxygen delivery (Maakaron et al., 2016).
Basedon your knowledge of pathophysiology of your patient’s medical problem, which
disease likely developed first that then initiated a “domino” effect in your patient’s life?
1. What PMH problem started first?
Colon Polyps
2. What PMH problem(s) followed as a “domino” effect?
a) Rectal bleeding
b) Anemia
c) Hypoalbuminemia
DIAGNOSIS:
What nursing priorities captures the “essence” of your patient’s current status and will
guide your plan of care? Provide one long term and one short term goal for each
diagnosis: (List each in the form of a NANDA three-part nursing diagnosis, MUST have a
minimum of three (3).
A. Nursing Diagnosis #1: Risk for ineffective tissue perfusion r/t decreased hemoglobin
a.e.b. hemoglobin of 6.9 secondary to anemia.
a. Short term goal: increase hemoglobin level to 9 or above
b. Long term goal: decrease rectal bleeding

Nursing Interventions: Rationale: Expected Outcome:
Nsg. Dx 1
 Monitor skin color and mucous
membranes
 Monitor vital signs and palpate
peripheral pulses.
 Administer blood products or
IV fluids as ordered by
physician PRN.
1. Skin pallor and pale
mucous membranes
may indicate lack of
appropriate blood
flow throughout the
body (Ackley &
Ladwig, 2014, pg.
811).
2. Blood pressure and
heart rate along with
strength of pulses
are indicators of
adequacy of
circulating volume
and tissue perfusion
or organ function
(Doenges et al.,
2014, pg. 779).
3. Maintains
circulating volume
and supports tissue
perfusion (Doenges
et al., 2014, pg.
780).
Mucous membranes and
skin will regain color
and no longer appear
pale. Blood pressure and
heart rate will increase
to WNL and peripheral
pulses will be palpable
at a strength of 2 or 3.
Tissue perfusion will
increase.
B. Nursing Diagnosis #2: Fatigue r/t blood loss a.e.b. irritability and restlessness
secondary to anemia.
a. Short term goal: Take at least two 1-hour naps today.
b. Long term goal: Sleep throughout the night (6-8 hours without waking up).
Nsg. Dx 2
 Encourage client to get more
rest and limit naps late in the
afternoon/ evening.
 Call the physician and ask
about potential
pharmacological treatments for
fatigue such as sleep aids.
 Collaborate with physician to
identify physiological causes of
fatigue such as anemia that
could be treated.
1. Dysfunction in sleep
schedule (too little or
too many interruptions)
can aggravate fatigue
(Ackley & Ladwig,
2014, pg. 349).
2. Pharmacological
therapy has been
shown to be effective
to reduce fatigue and
assist with sleep
(Ackley & Ladwig,
2014, Pg. 350).
3. If an etiology for
fatigue can be
The patient will take
naps earlier in the
daytime and so be
more tired at an
appropriate bedtime.
She will then sleep
through the night
without interruptions.
She will fall asleep
faster and stay asleep
longer with
medication such as
Benadryl. Fatigue
will be less due to
anemia treatment.

1. What is the worst possible/most likely complication to anticipate based on the
primary problem?
identified, the
condition should be
treated according to the
underlying cause.
Anemia is highly
correlated with fatigue
(Ackley & Ladwig,
2014, Pg. 350).
Patient will be more
energetic during the
day.
C. Nursing Diagnosis #3: Risk for shock r/t increased blood loss a.e.b. hematocrit of 22
secondary to rectal bleeding.
a. Short term goal: Decrease rectal bleeding. (Have less bloody diapers today).
b. Long term goal: Receive partial colectomy to remove affected area, per
gastroenterologist.
Nsg. Dx 3
 Monitor circulatory status vital
signs such as blood pressure
and heart rate.
 Administer oxygen as ordered.
 Monitor hydration status and
I’s and O’s as well as daily
weight.
1. The initial phase of
shock is characterized
by decreased cardiac
output and tissue
perfusion which will
result in changes in
blood pressure and
increased heart rate
(Ackley &Ladwig,
2014, pg. 732).
2. Administration of high
flow oxygen provides
early correction of risks
for shock and improves
survival rates (Ackley
& Ladwig, 2014, pg.
732).
3. Daily weights are an
important indicator of
fluid status. Intake and
output are a good
indicator of hydration
status and risk of
dehydration (Ackley &
Ladwig, 2014, pg.
732).
The patient’s blood
pressure and heart
rate will remain
stable. Oxygen
saturation percentage
will be increased
along with tissue
perfusion. Intake and
Output will be
relatively equal
indicating the patient
is adequately
hydrated.

The patient will have low iron and so will not be able to create more RBC’s. They
will then have low Hgb, Hct, and platelets and may bleed out/ hemorrhage.
2. What nursing assessments will identify this complication EARLY if it develops?
Vitals signs such as blood pressure, heart rate, and respirations need to be
monitored. Monitoring mucous membranes and skin color will also show signs of
shock. Hgb, Hct, and platelets should also be monitored, but take longer to get
results back.
3. What nursing interventions will you initiate if this complication develops?
I would give blood (as ordered) and fluids in order to increase the blood pressure
and respirations. I would also give oxygen in order to increase tissue perfusion.
EVALUATIONS:
All physicians’ orders have been implemented that are listed under medical management.
Evaluate the response of your patient to nursing and medical interventions during your
shift.
1. Has the status of your patient improved or not as expected to this point?
Patients hgb and hct have improved a lot during her stay.
2. Do your nursing plans/goals and interventions need to be modified in any way
after this evaluation assessment? Explain:
No I believe the goals and plan of care are still accurate and the patient
still needs to be monitored.
3. What will be the most important discharge/education priorities you will
reinforce with their medical condition to prevent future readmission with the
same problem? Explain:
- Education can be given on anemia and foods that contain iron in order to
keep iron levels high. Parents should be educated on the signs and
symptoms of shock, and when they should call their physician or bring
their child into the ER.
SBAR Report:
It is now the end of your shift. Effective and concise handoffs are essential to excellent care and
if not done well can adversely impact the care of this patient. You have done an excellent job at
this point, now finish strong and provide an SBAR report to the nurse who will be caring for this
patient after you 
Situation: Patient is a 14-month old female with a history of macrocephaly,
anemia, Hypoalbuminemia, and colon polyps. She is here for a
repeat colonoscopy. She received the colonoscopy at 1300 today and
has just come back from PACU.

Background: The patient has received numerous colonoscopies before. Patient
has history of anemia and received RBCs at 0100 last night because
hgb was 6.9.
Assessment: Patient seems to be doing well after the procedure. RR is slightly
elevatedbut patient does not show signs of respiratory distress. HR
and BP both WNL.
Recommendation(s): Patient can now be started on clear liquids and can be discharged
tomorrow as long as hgb and hct do not worsen. Patient will be
scheduled for partial colectomy next month.

References
Ackley, B.J., & Ladwig, G.B. (2014). Nursing Diagnosis Handbook: An Evidence-Based Guide
to Planning Care. Elsevier Mosby: Maryland Heights, Missouri.
Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2014). Nursing Care Plans. F.A. Davis
Company: Philadelphia, PA.
Hockenberry, M., & Wilson, D. (2009). Essentials of Pediatric Nursing. Elsevier Mosby: St.
Louis, Missouri.
Maakaron, J.E., Taher, A.T., & Conrad, M.E. (2016). Anemia. Medscape. Retrieved on August
15, 2016 from http://emedicine.mescape.com/article/198475-overview#a4
Sodium Phosphate (rectal). (2015). In Epocrates Essentials for Apple iOs (version 5.1) [mobile
application software]. Retrieved from
http://www.epocrates.com/mobile/iphone/essentials

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