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1. 1
Case study
Demographic data
Initials of infant y. B age: 9 mounth gender: Male
Dates of nursing care: 1/11/2015 admission date: 30/10/2015
DOB: 28/1/2015 DX: G/E
source of history: Mother and patient file
Address or home location : Al-Dhisha camp
Physical assessment:
Vital Signs
Pulse : Normal pulse ( 140 beats/minute).
Temperature: 37.1 C axillary
Respiration: 35-40 Breathing / min
General Appearance:
The patient awake, but fatigue, and responsive, he has healthy appearance his
facial expression looks not healthy during conversation, and during the physical
examination, and he interact with his mother.
Height & weight:
He has good body built and 61 cm height and 7 kg weight
type of feeding & frequency : breast feeding + cereal and fruits
Eyes:
As I notice that he able to see by his Both eyes, eye brows symmetrical and
coordinated in movement. brown in color, equal in size, round pupils. Hair of
eyebrow evenly distributed.
Ears:
He has symmetrical, same as facial in color. Able to hear in both ears; Normal
voice tones audible.
Mouth:
Pink in color, soft, moist, smooth in texture of 'lips and gum and inner mucosa'
The tongue central position, pink in color, slightly rough and move freely.

2. 2
Integumentary:
He has normal light color . moist, smooth , warm . with no problem lesions .
Head:
He has normal rounded, symmetrical skull, with no masses or nodules, good hair
distribution.
Musculoskeletal system:
The patient has equal size on both side of body and smooth coordinated
movement.
Genitourinary:
Pt urinate 3-4 Ɵmes daily and as his mother said no any problem Genitourinary
system.
Abdomen:
Smooth and relaxed abdomen, is flat rounded shape and symmetrical. The
umbilicus in the middle. No any large dull areas.
Pt complain of vomiƟng and diarrhea 3 days ago.
Chest and Lungs:
He has symmetrical chest, right and left shoulder and hips are at same height.
Chest wall intact,
no tenderness or masses. When inspection the rate was normally 53 b/m . Heart
rate is 152beat per minute.
Birth history:
40 weeks NSVD, single, 2900 g weight.
Family HX:
His mother didn’t have any medical history , unknown family history of
chronic diseases or congenital anomalies.
Surgical history :
Free past medical and surgical history.

3. 3
Pathophysiology:
Pathophysiology
Gastroenteritis is defined as vomiting or diarrhea due to infection of the small or
large bowel. The changes in the small bowel are typically noninflammatory, while
the ones in the large bowel are inflammatory. The number of pathogens required
to cause an infection varies from as few as one (for Cryptosporidium) to as many
as 108 (for Vibrio cholerae).
Diagnosis
Gastroenteritis is typically diagnosed clinically, based on a person's signs and
symptoms. Determining the exact cause is usually not needed as it does not alter
management of the condition. However, stool cultures should be performed in
those with blood in the stool, those who might have been exposed to food
poisoning, and those who have recently traveled to the developing world.
Diagnostic testing may also be done for surveillance. As hypoglycemia occurs in
approximately 10% of infants and young children, measuring serum glucose in this
population is recommended. Electrolytes and kidney function should also be
checked when there is a concern about severe dehydration.
Dehydration
A determination of whether or not the person has dehydration is an important
part of the assessment, with dehydraƟon typically divided into mild (3–5%),
moderate (6–9%), and severe (≥10%) cases. In children, the most accurate signs of
moderate or severe dehydration are a prolonged capillary refill, poor skin turgor,
and abnormal breathing. Other useful findings (when used in combination)
include sunken eyes, decreased activity, a lack of tears, and a dry mouth. A
normal urinary output and oral fluid intake is reassuring. Laboratory testing is of
little clinical benefit in determining the degree of dehydration. Thus the use of
urine testing or ultrasounds is generally not needed.

4. 4
Prevention
Lifestyle
A supply of easily accessible uncontaminated water and good sanitation practices
are important for reducing rates of infection and clinically significant
gastroenteritis. Personal measures (such as hand washing with soap) have been
found to decrease rates of gastroenteritis in both the developing and developed
world by as much as 30%. Alcohol-based gels may also be effective. Breastfeeding
is important, especially in places with poor hygiene, as is improvement of hygiene
generally. Breast milk reduces both the frequency of infections and their duration.
Avoiding contaminated food or drink should also be effective.
Vaccination
Due to both its effecƟveness and safety, in 2009 the World Health OrganizaƟon
recommended that the rotavirus vaccine be offered to all children globally. Two
commercial rotavirus vaccines exist and several more are in development. In
Africa and Asia these vaccines reduced severe disease among infants and
countries that have put in place national immunization programs have seen a
decline in the rates and severity of disease. This vaccine may also prevent illness
in non-vaccinated children by reducing the number of circulating infections. Since
2000, the implementaƟon of a rotavirus vaccinaƟon program in the United States
has substantially decreased the number of cases of diarrhea by as much as 80
percent. The first dose of vaccine should be given to infants between 6 and 15
weeks of age. The oral cholera vaccine has been found to be 50–60% effecƟve
over 2 years.
Management
Gastroenteritis is usually an acute and self-limiting disease that does not require
medication. The preferred treatment in those with mild to moderate dehydration
is oral rehydration therapy (ORT). Metoclopramide and/or ondansetron, however,
may be helpful in some children, and butylscopolamine is useful in treating
abdominal pain.
Rehydration

5. 5
The primary treatment of gastroenteritis in both children and adults is
rehydration. This is preferably achieved by oral rehydration therapy, although
intravenous delivery may be required if there is a decreased level of
consciousness or if dehydration is severe. Oral replacement therapy products
made with complex carbohydrates (i.e. those made from wheat or rice) may be
superior to those based on simple sugars. Drinks especially high in simple sugars,
such as soft drinks and fruit juices, are not recommended in children under 5
years of age as they may increase diarrhea. Plain water may be used if more
specific and effective ORT preparations are unavailable or are not palatable. A
nasogastric tube can be used in young children to administer fluids if warranted.
Dietary
It is recommended that breast-fed infants continue to be nursed in the usual
fashion, and that formula-fed infants continue their formula immediately after
rehydration with ORT. Lactose-free or lactose-reduced formulas usually are not
necessary. Children should continue their usual diet during episodes of diarrhea
with the exception that foods high in simple sugars should be avoided. The BRAT
diet (bananas, rice, applesauce, toast and tea) is no longer recommended, as it
contains insufficient nutrients and has no benefit over normal feeding. Some
probiotics have been shown to be beneficial in reducing both the duration of
illness and the frequency of stools. They may also be useful in preventing and
treating antibiotic associated diarrhea. Fermented milk products (such as yogurt)
are similarly beneficial. Zinc supplementation appears to be effective in both
treating and preventing diarrhea among children in the developing world.
Antiemetics
Antiemetic medications may be helpful for treating vomiting in children.
Ondansetron has some utility, with a single dose being associated with less need
for intravenous fluids, fewer hospitalizations, and decreased vomiting.
Metoclopramide might also be helpful. However, the use of ondansetron might
possibly be linked to an increased rate of return to hospital in children. The
intravenous preparation may be given orally if clinical judgment warrants.
Dimenhydrinate, while reducing vomiting, does not appear to have a significant
clinical benefit.

6. 6
Antibiotics
Antibiotics are not usually used for gastroenteritis, although they are sometimes
recommended if symptoms are particularly severe or if a susceptible bacterial
cause is isolated or suspected. If antibiotics are to be employed, a macrolide (such
as azithromycin) is preferred over a fluoroquinolone due to higher rates of
resistance to the latter. Pseudomembranous colitis, usually caused by antibiotic
use, is managed by discontinuing the causative agent and treating it with either
metronidazole or vancomycin. Bacteria and protozoans that are amenable to
treatment include Shigella Salmonella typhi, and Giardia species. In those with
Giardia species or Entamoeba histolytica, tinidazole treatment is recommended
and superior to metronidazole. The World Health Organization (WHO)
recommends the use of antibiotics in young children who have both bloody
diarrhea and fever.
Antimotility agents
Antimotility medication has a theoretical risk of causing complications, and
although clinical experience has shown this to be unlikely, these drugs are
discouraged in people with bloody diarrhea or diarrhea that is complicated by
fever. Loperamide, an opioid analogue, is commonly used for the symptomatic
treatment of diarrhea. Loperamide is not recommended in children, however, as
it may cross the immature blood–brain barrier and cause toxicity. Bismuth
subsalicylate, an insoluble complex of trivalent bismuth and salicylate, can be
used in mild to moderate cases, but salicylate toxicity is theoretically possible

7. 7
Ingestion of fecally
contaminated food &
water
Attempted defecation
(Tenesmus)
Mild Diarrhea
(2-3 Stools)
Secretion of F&E in the
intestinal lumen
Excessive gas formation
Direct invasion of the
bowel wall
GI Distention
Nausea & Vomiting
Stimulation and
destruction of mucosal
lining of the bowel wall
Endotoxins are
released
Digestive & absorptive
malfunction
Increase peristaltic
movement
LI is overwhelmed &
unable to reabsorb the
lost fluid
Intense Diarrhea (>10x)
(Watery Stool)
Fluids & Electrolytes
Imbalance
Serious Fluid Volume
Deficit
Increased protein in the
lumen
Hypovolemic Shock
Death
Predisposing Factors
• Age
• Malnutrition
Precipitating Factors
• Contaminated
food and water
If untreated...

8. 8
Lab results:
SAMPLE PATIENT
VALUE
NORMAL
VALUE
INFERENCE
Hemoglobin 10.5 mg/dl 12.3-15.3 mg/dl anemia
RBC 4.58 million/cu 4.5-5.1 million/cu Normal
Hematocrit 33% 35.9-44.6% Anemia
WBC 14300/cumm 4,400-11,000 Sign of infection
Renal function
test
BUN 13 mg/dl 7-18mg/dl Normal
Serum creatinine 0.4 mg/dl 0.7-15 mg/dl 0.14 less
Liver function
test
K 4.3 mmol/L 3.5 – 5.1 mmol/L Normal
Na 135 mEq/L 135 -145 mEq/L Normal
Total protein 6 mg/dl 6-8 mg/dl Normal

9. 9
Medications:
Drug NameDrug NameDrug NameDrug Name
& Dose& Dose& Dose& Dose
RationalRationalRationalRational ActionActionActionAction Side effectSide effectSide effectSide effect NSG ImplicationsNSG ImplicationsNSG ImplicationsNSG Implications
Ampicillin
T(Ampicillin)
150 mg X 4
Rout :IV infusion
Time
6am 12MD
6pm 12MN
Treatment of
infection
Bactericidal action
against sensitive
organisms; inhibits
synthesis of bacterial cell
wall, causing cell death.
Lethargy,
hallucinations,
seizures, Anemia,
furry tongue, black
“hairy” tongue,
nausea, vomiting,
diarrhea, Rash,
fever.
Check IV site carefully
for signs of thrombosis
or drug reaction.
Stop if any reaction or
allergy.
Monitor sodium level
because each gram of
ampicillin contains 2.9
mEq of sodium
•
If large dose are given
or if therapy is
prolonged, bacterial or
fungal super infection
may occur
•
Watch for signs of
hypersensitivity
Iv fluid 500 cc D/S 0.18 q 24 hrs
Nursing diagnoses list (NANDA) prioritized
• Acute Pain R/TO increase vascular permeability.
• Deficient Fluid Volume R/To vomiting and dehydration .
• Activity intolerance related to generalized weakness AEB limited physical
activity.
• Imbalanced Nutrition Less Than Body Requirements related to
anorexia, vomiting, and irregularities in body perception.

10. 10
• Knowledge deficit and information related to the conditions and lack
of coping skills.
Allergies: ( food , drugs , others )
No allergies from food and drugs . but c/o Spring allergies and dust.
Immunization:
Vaccine Age
BCG + HB 1st Day
HB + IPV(Salk ) 1 month
OPV(sabin ) +DPT + Hib +
IPV
2 Month
OPV + DPT + Hib 4 Month
HB + DPT + OPV + 6 Month
Measles 9 Month
feeding History
Breast feeding unil 9 month of age( for now)
Start take cerlac at 4 months
At 7 month start eat regular diet
Elimination history
Pt urinate 3-4 times daily.
Pertinent family nutritional
Good nutritional and regular diet . Gets all the nutrients , Calcium and phosphorus
and all the vitamins.
Fluid and electrolytes assessment:
description all fluid in take (IV , PO ) ,flushing , blood products:
The patient on oral intake, Iv fluid 500 cc D/S 0.18 q 24 hrs no blood products.
description all out put (stool, urine, vomitus blood sampling) :
PT stool is normal in amount, color, consistency, and frequency, 2 time per day. but now 5-6
times r/to infection and GE. And 6 times vomiting.

11. 11
Urine normal in color, amount, and frequency, 3 times per day.
of vomiting in hospital.
total 24 hr volume intake:
6 times breast feeding 6*30= 180 ml and 150 ml juice .
Fluid requirement:
Patient has sign of dehydration and fluid loss.
For children 7 kg the daily fluid requirement is 1000 mL + 50 mL/kg for every
kg over 10
According to this the patient Wight 7kg need 1350ml Q 24 hrs.
Output requirement:
1-2ml/kg/hr
1or 2*7*1=14ml/hr
336ml/day
Intake to output:
In take = out put
Reaction of family to hospitalization ( expressed feeling verbal & nonverbal
by
family , perception of illness , sibling , coping mechanism , parenting skills).
The mother hope her son will soon discharge from hospital with healthy
condition, and she ask the God for his care, she understand the pathology of her
son and understand the risk, she use religious coping mechanism.
Current treatments / nursing care:
A 9 month , male admitted to PED as a case G/E: plan to do CBC,LFT, U/A, stool
/A , BUN, Creatinin, IV fluid 100 cc state , IV fluid 500 cc D/S 0.18% / 24 hrs .
(Ampicillin)
150 mg 1X 4.
Keep same RX

12. 12
Nursing Care Plans
The nursing goals for patients with Acute Gastroenteritis are toward avoiding dehydration and
management of diarrhea.
DiarrheaDiarrheaDiarrheaDiarrhea
Diarrhea is defined as an increase in the frequency, volume and fluid content of stool. Rapid
propulsion of intestinal contents through the small bowel results in diarrhea. Diarrhea is a
hallmark sign of gastroenteritis.
Assessment
Patient may manifest
• Hyperactive bowel sounds
• Audible borborygmi
• Passage of loose liquid watery stools for more than 3 times
• Poor skin turgor
• Dehydration
• Dry lips and oral mucosa
• Altered LOC
• Pain
• Stomach cramping
Nursing Diagnosis
• Diarrhea
Outcomes
• Patient will verbalize understanding of causative factors and rationale for treatment regimen.
• Patient will reestablish and maintain normal pattern of bowel functioning AEB passage of semi-
solid stools

13. 13
Nursing Interventions Rationale
Establish rapport To gain patient’s trust
Assess general condition and vital signs For baseline data
Auscultate abdomen For presence, location, and characteristics of
bowel sounds
Discuss the different causative factors and
rationale for treatment regimen
For patient education
Restrict solid food intake To allow for bowel rest and reduce intestinal
workload
Provide for changes in dietary intake To prevent foods/substances that precipitate
diarrhea
Limit caffeine and high-fiber foods and so as
fatty foods
To prevent gastric irritation
Promote use of relaxation technique To decrease stress and anxiety that can aggravate
diarrhea
Encourage oral fluid intake of fluids containing
electrolyte
For fluid replacement
Recommend products like yogurt and cultured
milk
To restore normal flora
Emphasize importance of handwashing To prevent spread of infectious diseases

14. 14
Acute PainAcute PainAcute PainAcute Pain
One of the manifestations of gastroenteritis is abdominal pain. During the course of
inflammation, the body’s immune response, causing the release of cytokine and prostaglandin
causing an increase in vascular permeability and causes pain, which felt by the patient in the
abdomen.
Assessment
Patient may manifest
• Abdominal Pain
• Appears weak
• Limited range of motion
• Restlessness
• Verbalization of pain with a pain
• Facial grimaces
• Irritability
• Impaired thought process
• Reduced interaction with people
• sleep disturbances
• Diaphoresis
Nursing Diagnosis
• Acute Pain
Outcomes
• Patient will report a decrease of pain.
• Patient will be free from pain and demonstrate relaxational skills.

15. 15
Nursing Interventions Rationale
Review factor that aggravate or alleviate pain To lessen/alleviate pain caused by various factors
(administer meds via IV push)
Instruct the SO to massage the area where
pain is elicited if not contraindicated
To reduce pain and promote relief/comfort
Encourage pain reduction techniques To promote healing and provide non-
pharmacological pain reduction techniques
Provide adequate rest To reduce pain and promote relief/comfort
Provide diversional activities like socialization For client’s comfort and relief from pain
Administer analgesics to maintain acceptable
level of pain if not contraindicated
For client’s comfort and relief from pain
Instruct client to perform deep breathing
exercises (DBE)
Deep breathing exercises may reduce pain
sensation/ used in pain management
Monitor effectiveness of pain medications To promote timely intervention/ revision of plan
of care

16. 16
Deficient Fluid VolumeDeficient Fluid VolumeDeficient Fluid VolumeDeficient Fluid Volume
Rapid propulsion of intestinal contents through the small bowels may lead to a serious fluid
volume deficit. The body would want to expel the foreign objective as much as possible thus it
doesn’t undergo its “normal” speed, with that, the digestive system organs are not able to absorb
the excess fluids that are usually absorbed by the body.
Assessment
Patient may manifest
• passage of loose watery stool
• vomiting
• abdominal cramping
• dehydration
• nausea
• fatigue
• weakness
• nervousness
• confusion
• weight loss
• decreased skin turgor
• decreased urine output
• dry mucous membrane
• fever
Nursing Diagnosis
• Deficient fluid volume RT excessive losses through normal routes AEB frequent passage of loose
watery stool
Outcomes
• Patient will report understanding of causative factors for fluid volume deficit
• Patient will maintain fluid volume at functional level AEB well hydrated, intake is equal as
output, and normal skin turgor.

17. 17
Nursing Interventions Rationale
Maintain adequate hydration, increase fluid
intake.
To prevent dehydration & maintain hydration
status.
Provide frequent oral care To prevent from dryness
Administer Intravenous fluids as prescribed To deliver fluids accurately and at desired rates.
Determine effects of age. Very young and extremely elderly individuals are
quickly affected by fluid volume deficit
Restrict solid food intake, as indicated To allow for bowel rest and to reduced intestinal
workload.
Discuss individual risk factors/ potential
problems and specific interventions
To prevent or limit occurrence of fluid deficit.

18. 18
Activity IntoleranceActivity IntoleranceActivity IntoleranceActivity Intolerance
Activity intolerance is insufficient physiological or psychological energy poor endure or
complete required or desired daily activities. Because of low hgb and hct level there will be
decrease oxygen being delivered to the tissues of the body since the hgb is responsible for the
oxygenation of tissue. As a compensatory mechanism, the body will increase its demand of
oxygen by increasing respiratory rate of the patient which results then to fatigue. Because of this
there will be fast consumption of ATP leading to weaker contractions thus causing muscle
weakness. And if the patient has muscle weakness there will be activity intolerance.
Assessment
Patient may manifest
• Weakness
• Restlessness
• Physical inactivity
• Increase respiratory rate
• Fatigue
• Low hgb count
• Low hct count
Nursing Diagnosis
• Activity intolerance related to generalized weakness AEB limited physical activity.
Outcomes
• Patient will identify negative factors affecting activity intolerance and eliminate or reduce their
effects.
• Patient will participate willingly in necessary or desired activities.

19. 19
Nursing Interventions Rationale
Provide health teaching on the client
regarding the organization and time
management technique to prevent while on
activity
To enhance patient ability to participate in
activity
Provide enough air coming from the electric
fan or from the window
To monitor patients response to activities
Develop and adjust simple activity like
brushing his teeth
To prevent overexertion
Assist client with activity To protect patient from injury
Promote comfort measures on the activity To prevent over-exhaustion
Cluster nursing care To prevent over-exhaustion
Ascertain ability to stand and move about
degree of assistance
To determine current status and needs
Encourage complete bed rest For patient recuperation and recovery
Other Possible NursingOther Possible NursingOther Possible NursingOther Possible Nursing DxDxDxDx
• Imbalanced Nutrition: Less than Body Requirements due to insufficient intake and excessive
output;
• Risk for Deficient Fluid Volume (if diarrhea does not occur or intake of fluids is insufficient but
does not have any signs of dehydration);
• Hyperthermia RT inflammatory process.

20. 20
Educational assessment and teaching pathways:
What is gastroenteritis?
Gastroenteritis can cause vomiting and diarrhea (very frequent, watery bowel
movements). This illness is very common in children.
Gastroenteritis is usually caused by a virus. It can also be caused by bacteria (germs) or
parasites.
Most children with gastroenteritis get better without medicine in a few days. However, it
is very important to prevent dehydration.
What is dehydration?
Dehydration is the “drying out” of the body that happens when your child loses more
fluids than he or she is able to drink.
Dehydration happens quickly in infants and very small children. These children have less
“extra” fluids in their bodies to lose.
How to prevent dehydration in your child?
• If you breast-feed your baby, keep on doing this, and try to breast-feed more often.
• If you bottle-feed, keep using the regular formula, and try to feed your child more often.
• If your child is older, make sure that he or she drinks enough liquids to replace the fluids
that are lost in diarrhea and vomiting.
• An older child who is not nauseated (feeling like throwing up) or vomiting can keep
eating regular foods. Encourage your child to drink as much liquid as he or she can. Any
liquids your child will drink are OK, as long as your child eats some solid foods, too.
Fatty foods and drinks that are high in sugar (such as juices and soft drinks) might make
the diarrhea a little worse. It helps to feed your child solid foods like noodles or rice,
along with meat that isn't fatty. Fruits and vegetables and yogurt may be the best
choices.
If your child is nauseated but not vomiting, give him or her small sips of liquid every few
minutes. This is less likely to cause vomiting than drinking a lot at once. If your child will
not eat any solid foods, is vomiting over and over, or will not drink liquids, you should try
one of the special “Oral Rehydration Solution” drinks described on the next page.

21. 21
How do I know if my child is getting dehydrated?
You can suspect dehydration if your child has had vomiting or diarrhea and has any of
these signs:
• Feeling thirsty but drinking liquids makes the child vomit
• Dry lips and mouth
• A dark color or a strong smell to the urine (and not urinating very often or very much)
• Feeling dizzy when sitting or standing up (in older children)
• Little or no tears when crying (in babies)
• Sunken eyes (in babies and toddlers)
• Not paying attention to toys or television, or even being difficult to wake up (this is a sign
of very bad dehydration)
• Vomiting up everything he or she drinks or eats
How to treat dehydration?
If the dehydration isn't too bad, you can care for your child at home with help from your
doctor. It takes a lot of care and time. It is best to use special liquids called “Oral
Rehydration Solutions” (or “ORS” for short). These are drinks designed for children who
are dehydrated. They contain water, sugar and a special mix of mineral salts like sodium
and potassium.
Other “clear liquids” like soft drinks, tea, apple juice, Jello-water, chicken broth or “sport
drinks” like Gatorade don't have the right mix of water, sugar and mineral salts. They
might even make the diarrhea worse.
Drug stores and grocery stores carry several brands of ORS, with brand names like
Pedialyte, Infalyte, Rehydralyte, Resol and Naturalyte. You might also find “generic”
brands of ORS. They all work the same and are safe when you follow the directions.
Start by giving your child one or two teaspoons every one or two minutes. This adds up
to over a cup an hour. Even if your child vomits again, quite a lot of this fluid will stay
down. That helps fix the dehydration.
If your child does well, you can slowly give bigger sips a little less often—every 5
minutes. When your child is no longer dehydrated and isn't nauseated or vomiting, you
can start giving regular food and drinks again.

22. 22
Using medicine for diarrhea?
Medicines for diarrhea don't work very well. The best treatment is to prevent or treat
dehydration.
When you should seek health care providers ?
In general, if your child is under two years old and has vomiting and diarrhea for more
than 12 hours, you should take him or her to your doctor. This is very important if the
child is vomiting often, or if the amount of diarrhea is large, or if the child also has a
fever. Call your doctor right away if your child:
• Has pain in the stomach along with the vomiting
• Has blood in the diarrhea
• Is under six months of age
• Has any of the signs or symptoms of dehydration mentioned in the list above.

23. 23
References
1. Wong's Essentials of Pediatric Nursing, 9th Edition
2. Kozier & Erb's Fundamentals of Nursing Concepts, Process, and
Practice (9th edition) (2011)
3. Amy M. Karch lippincott's nursing drug guide: Lippincott Williams
& Wilkins (2009).
4. Bates’ Instructors Manual Guide to Physical Exam and History
Taking (8 th edition) Philadelphia: Lippincott Williams &
Wilkins(2006).
5. Meg Gulanick, Judith L. Myers Nursing Care Plans : Nursing
Diagnosis and Intervention (6th edition) : Elsevier Health Sciences
(2006)