This document provides care plans for various medical conditions and procedures. It includes care plans for a neonate with hyperbilirubinemia, risk of overdose from drug toxicity, appendicitis post-operation, and sickle cell crisis. The care plans identify problems, goals, and interventions related to fluid balance, pain management, infection risk, and other common issues for each condition.

1. Care Plan Help

2. Neonatal Hyperbilirubinemia
FluidVolume Deficit r/t diarrhea, fluid intake, and/or phototherapy
Goals: Body fluids of the neonate will be accurate for weight, height, and age
Interventions:
 Maintain strict intake and output
 Administer fluid or water in between feedings
 Record amount/quality of stools
 Asses skin turgor/ sunken fontanels
Impaired Skin Integrity r/t Hyperbilirubinemiaand phototherapy
Goals: Infant skin integrity will be maintained
Interventions:
 Assess skin every 6 hours
 monitor direct and indirect bilirubin
 keep skin clean and moisturized
 massage reddened areas/areas that stand out
Hyperthermia r/t phototherapy
Goals: Infants temperature will stay within 35.5- 37.2 degrees Celsius
Interventions:
 Obtain vital signs every 2 hours
 Keep room at a neutral ambient temperature

3. Overdose
Risk for injury (hepatic/renal toxicity) r/t adverse effects of drug overdose
Goals: Patient will remain free of signs of hepatic or renal toxicity.
Patient pertinent lab values (acetaminophen, liver enzymes, creatinine, PT ,etc.) will
remain within normal values.
Interventions:
 Obtain blood collection for ordered lab values
 Monitor renal function tests and strict Intake and Output
 Perform neurologic exam as indicated by healthcare provider
 Obtain vital signs every 2 hours
Ineffective impulse control r/t suicidal feeling
Goals: Patient will remain free from harm
Cooperate with behavioral modification plan
Interventions:
 Ensure that a sitter is present with patient at all times following protocol of orders
 Refer to mental health treatment and communicate with Stress Center if indicated
Risk for suicide r/t previous suicide attempt
Goals: Patient will obtain no access to harmful objects
Patient will meet with/be assessed by a psychologist of other Stress Center related physician as
indicated
Patient will discuss/disclose suicidal thoughts with a staff member if suicidal ideation is present
Interventions:
 Develop a positive, therapeutic relationship with patient; do not make promises that can’t
be kept
 Refer for mental health counseling
 Call for a sitter and do not leave the patient alone while hospitalized

4. Cardiac
Tetralogy of Fallot, Transposition of the Great Arteries, Atrial/Ventricular Septal Defect, Patent
Ductus Arteriosus, Aortic/Pulmonic Stenosis
Impaired gas exchange r/t altered pulmonary blood flow secondary to congenital
heart disease
Goals: Patient will remain free of signs of respiratory distress (including hypoxia, nasal flaring,
intercostal retractions, grunting, etc.)
Parents/care providers will be able to verbalize signs and symptoms of hypoxia, tet. spells, and
any respiratory distress relevant to child’s illness
Interventions:
 Monitor respiratory rate, depth, and ease of respiration every 2 hours
 Monitor continual oxygen saturation by pulse oximetry
 Educate care providers on signs of respiratory distress and answer any questions
Altered Cardiac Output r/t ineffective circulationsecondary to specific anatomic
defect
Goals: Patient will show adequate cardiac output as evidenced by blood pressure, heart rate, and
rhythm within normal values appropriate to illness.
Patient’s urine output will be 1-2 ml/kg/hour
Interventions:
 Monitor for signs of decreased cardiac output such as fatigue, dyspnea, edema,
etc.
 Monitor orthostatic blood pressure and daily weights
 Administer oxygen as needed per orders
 Give knee-chest position during tet. spells
 Provide restful environment by clustering care and minimizing unnecessary
disturbances
Imbalanced Nutrition: less than body requirements r/t excessive energy demands
required by increasedcardiac workload
Goals: Patient will progressively gain weight as expected/ to desired goal.
Patient will consume adequate nutrition, including being given supplements if indicated.
Interventions:
 Obtain daily weights
 Monitor and document food intake including types and amount of foods
eaten/beverages drank.
 Call physician if child is not gaining weight or shows symptoms of malnutrition.

5. Oncology
Fever/Neutropenia
Risk for infectionr/t immunosuppression, invasive procedures, malnutrition, or
pharmaceutical agents
Goals: Patient will remain free from symptoms of infection
Patient will maintain white blood cell count and differential within normal limits.
Interventions:
 Promote good hand washing procedures by both staff and visitors, by educating
on the importance.
 Monitor temperature and vitals every 2 hours.
 Monitor CBC with differential WBC and other related lab values.
 Obtain cultures as indicated.
Risk for impairedoral mucous membrane r/t immunosuppression
Goals: Patient will maintain moist, intact oral mucous membranes that are free of ulceration,
inflammation, infection, and debris.
Intervention:
 Inspect oral cavity at least once per day.
 If indicated, encourage patient to brush teeth with soft toothbrush at least twice
per day.
 Encourage patient to use mouth wash as ordered.

6. Chemotherapy Administration
Nausea r/t chemotherapy administration
Goals: Patient will verbalize any nauseous feelings as they arise.
Patient will state relief of nausea after an intervention has been completed.
Interventions:
 Administer an anti-emetic prior to and after chemotherapy administration start, as
ordered.
 Document each episode of nausea and/or vomiting separately, as well as
effectiveness of interventions.
Ineffective individual coping r/t situational crisis
Goals: Patient will demonstrate normal adaptive coping methods.
Patient will show facial expressions, gestures, and activity levels that reflect decreased distress
within 30 minutes of chemotherapy administration.
Interventions:
 Encourage drawing or other therapeutic play for expression of feelings.
 Discuss how to behave during treatments.
Fatigue r/t lack of sleepprivacy/control
Goals: Patient will sleep for enough hours appropriate to their age.
Patient will state, if able, feeling rested.
Interventions:
 Cluster care as much as possible to avoid unnecessary interruptions during normal
rest and sleep times.
 Alter patient’s room to allow designated periods of rest

7. Appendectomy
Acute Pain r/t distensionof intestinal tissues by inflammation, surgical procedure
Goals: Patient will state a decreased pain score after intervention has been completed (or if
unable to speak, will show signs of decreased pain such as decreased HR, BP, and facial
expressions.)
Patient will state/demonstrate the ability to obtain sufficient amounts of sleep and rest.
Interventions:
 Explain pain management plan with patient or with family if patient is unable to
understand.
 Assess pain intensity (by 0-10 verbal statement or symptoms of pain- facial
grimace, position, vitals) every 4 hours and again before and after an intervention
is completed.
 Administer pain medication as ordered.
 Offer non-pharmacological treatments for pain such as hot/cold packs, relaxation
techniques/deep breathing, aroma therapy, music therapy, etc.
Risk for fluid volume Deficit r/t NPO post. operative, hypermetabolic state (fever,
healing process)
Goals: Patient will maintain blood pressure, pulse and body temperature within their normal
limits.
Patient will maintain urine output of 1-2 ml/kg/hour.
Interventions:
 Monitor strict input and output.
 Obtain daily weights.
 Monitor vital signs every 4 hours.
 Administer fluids as ordered, and encourage fluids with and between meals.
Risk for infectionr/t appendicitis perforation of the appendix, peritonitis, abscess
formation, surgical incision
Goals: Patient will remain free from signs of infection.
Patient will achieve timely wound healing within acceptable time frame per surgeon.
Interventions:
 Practice and educate on proper hand hygiene and aseptic wound care.
 Inspect incision and dressings, while noting characteristics of the wound such as
drainage, erythema, or inflammation.
 Monitor vital signs every 4 hours.
 Administer antibiotic as ordered.

8. Hematology
Factor Deficiency
Risk for bleeding injury r/t weakness of the defense system secondary to hemophilia
Goals: Patient will have no bleeding injuries while hospitalized.
Interventions:
 Create an environment that is safe and allows the regulatory process for the
patient, and encourage parents to choose activities that are acceptable and safe.
 Perform and document admission risk for falls.
 Monitor for signs of bleeding, including: bleeding gums, hematemesis, petechiae,
hematuria, and blood in the stool
 Provide factor VIII concentrates and blood products as ordered.
Sickle Cell Crisis
Acute pain r/t sickle cell crisis.
Goals: Patient will state a decreased pain score after intervention has been completed (or if
unable to speak, will show signs of decreased pain such as decreased HR, BP, and facial
expressions.)
Patient will state/demonstrate the ability to obtain sufficient amounts of sleep and rest.
Interventions:
 Explain pain management plan with patient or with family if patient is unable to
understand.
 Assess pain intensity (by 0-10 verbal statement or symptoms of pain- facial
grimace, position, vitals) every 4 hours and again before and after an intervention
is completed.
 Administer pain medication as ordered.
 Offer non-pharmacological treatments for pain such as hot/cold packs, relaxation
techniques/deep breathing, aroma therapy, music therapy, etc.
Ineffective tissue perfusion r/t vaso-occlusive nature of sickling, inflammatory
response
Goals: Patient will demonstrate adequate tissue perfusion, evidenced by stable vital signs and
palpable peripheral pulses.
Interventions:
 Monitor vital signs every 2 hours, paying attention to hypotension and increased
or shallow respirations.
 Assess skin for pallor, cyanosis, coolness, and delayed capillary refill.

9. Renal
Nephrotic Syndrome
Impaired urinary elimination r/t sodium and water retention
Goals: Patient will demonstrate voiding frequency appropriate to age (ml per kg/hr)
Patient will state absence of pain or increased urgency during elimination
Interventions:
 Monitor strict Intake and Output
 Perform focus physical assessment, palpating the lower abdomen and checking
for bladder distension
 Perform straight catheterization if indicated to relieve bladder distension
Excess fluid volume r/t water retention and decreased oncotic pressure
Goals: Patient will maintain urine output of 0.5 mL/kg/hr or more.
Patient will maintain vitals signs within their normal limits.
Interventions:
 Restrict fluid intake
 Monitor daily weight for sudden increases, and strict intake and output
 Encourage diet with low sodium and high protein
 Monitor serum albumin level and provide protein intake as appropriate
Risk for infection r/t decreased immune systemsecondary to loss of protein in urine
Goals: Patient will show no signs of infection while hospitalized.
Interventions:
 Restrict visitors with colds to in order to protect the patient
 Wash hands thoroughly and encourage staff and visitors/family to do so as well.
 Monitor vital signs every 4 hours
Imbalanced nutrition: less than body requirements r/t disease process
Goals: Keep the patient at an appropriate weight for age and height.
Interventions:
 Provide small, frequent meals that are low in sodium and high in protein and
carbs
 Provide nutritional supplementation as indicated
 Monitor daily weights for decrease

10. Ear, Nose, Throat
Tonsillectomy/Adenoidectomy
Acute pain r/t surgical procedure
Goal: Patient will report pain at an acceptable number for them (0-10 pain score) or, if unable to
speak, will show no physiological signs of pain (facial grimaces, tachycardia, hypertension, etc)
Patient will obtain enough sleep/relax as appropriate for age
Interventions:
 Pain will be assessed every 4 hours
 Pain medications will be administered as ordered, with pain level being
asked/observed both before and 30 minutes after medication intervention
 Patient will be offered non-pharmacological treatments for pain including heat/ice
packs, popsicles, musical therapy, changes in position, etc.
Risk for bleeding r/t surgical procedure
Goals: Patient will have no bleeding observed from the nose or mouth
Patient will show not show signs of excessive swallowing or frequent clearing of throat
Interventions:
 Observe inside of mouth and nose for any indications of bleeding
 Obtain vital signs every 4 hours and monitor for irregular breathing patterns or
tachycardia
Risk for infection r/t factors of surgery
Goals: Patient will show no signs of infection, including being afebrile and vitals signs within
appropriate limits for that patient
Interventions:
 Vital signs and temperature will be taken every 4 hours
 Patient will be given prophylactic antibiotics as ordered
 Nurse will educate care providers on signs and symptoms to look for of infection

11. Cochlear Implant
Risk for infectionr/t surgical procedure
Patient will show no signs of infection, including being afebrile and vitals signs within
appropriate limits for that patient
Interventions:
 Vital signs and temperature will be taken every 4 hours
 Patient will be given prophylactic antibiotics as ordered
 Nurse will educate care providers on signs and symptoms to look for of infection
 Nurse will monitor for any drainage coming from patient’s ear
Acute pain r/t surgical procedure
Goal: Patient will report pain at an acceptable number for them (0-10 pain score) or, if unable to
speak, will show no physiological signs of pain (facial grimaces, pulling on ear, tachycardia,
hypertension, etc.)
Patient will obtain enough sleep/relax as appropriate for age
Interventions:
 Pain will be assessed every 4 hours
 Pain medications will be administered as ordered, with pain level being
asked/observed both before and 30 minutes after medication intervention
 Patient will be offered non-pharmacological treatments for pain including heat/ice
packs, popsicles, musical therapy, changes in position, etc.

12. Hospice
Ineffective family coping r/t prolongeddisease/disability progressionthat exhausts
the supportive capacity of significant persons
Goals: Family will be able to verbalize and express a realistic understanding and expectations of
the patient
Family will be able to identify and verbalize resources available to them to help them cope
Interventions:
 Assess level of anxiety present in the family
 Establish a trusting and caring rapport with the patient and family
 Provide family with relevant resources (brochures, verbal information, contact
info)
 Answer families questions as appropriate or contact the appropriate provider if
unable
Activity Intolerance r/t generalized weakness, pain, progressive disease state/
debilitating condition
Goals: Patient will obtain appropriate hours of sleep and rest for age and condition.
Patient will remain free of preventable discomfort and/or complications
Interventions:
 Assess sleep patterns and note changes in emotional behaviors
 Recommend scheduling activities for the hours when the patient seems to have
the most energy; adjust activities as necessary
 Encourage patient to do whatever possible activities of daily living themselves
 Provide supplemental oxygen as indicated
Anticipatory grieving r/t anticipated loss of physiological well-being, perceived
death of patient
Goals: Patient will identify and verbalize feelings, if capable.
Patient will accept assistance in meeting the needs of themselves and their family
Interventions:
 Develop a trusting rapport with the patient/family by being kind and using
therapeutic communication
 Keep patient and family informed on physical care and support in symptom
control, and inform about health care options at the end of life including palliative
care, hospice care, and home care
 Answer patients and families questions with honesty and kindness

13. Pain r/t progressive disease state/debilitating condition
Goals: If possible, patient will state that pain is relieved/controlled.
Patient will obtain enough sleep/relax as appropriate for age
Interventions:
 Assess pain every 4 hours and before and after an intervention
 Follow pain management protocol; administer pain medications as appropriate
 Offer non-pharmacological treatments of pain
 Encourage patient and family to express feelings of concern regarding narcotic
use

14. Created by: Abby Bullerdick
Purdue University School of Nursing
Ackley, B,J., Ladwig, G.B. (2014).Nursing Diagnosis Handbook:An Evidenced Base Guide to Planning
Care. Missouri: Mosby Elsevier.