My nursing care plan for a patient

1. DA NANG UNIVERSITY OF MEDICAL TECHNOLOGY AND PHARMACY
FACULTY OF NURSING
CARE PLAN
Student’s name: NGUYEN HOA VAN CHI
Class: DH DDDK09A
Patient’s full name: PHAN NGUYEN BANG DI Age: 8-month-old Room: 501 Department: Pediatric Department
Diagnosis: Main diseases: Pneumonia Comorbidities: None Complications: None
Date ASSESSMENT NURSING
DIAGNOSIS
PLANNING IMPLEMENTARY EVALUATION
3/15/2
4
1. The patient is alert
and conscious. No
signs of pallor,
cyanosis, or
subcutaneous
bleeding.
V/S taken as follows:
T: 36.8o
C
P: 115bpm
- Assess the
patient’s
consciousness
and generalized
signs
- Monitor the vital
signs
-Assess the patient’s
consciousness and generalized
signs
-Daily monitoring should include the
vital signs, with a particular focus
on the function of circulatory,
respiratory, digestive system, and
nervous systems twice a day at
9:00 and 15:00
-The patient is alert
and conscious—no
signs of pallor,
cyanosis, or
subcutaneous
bleeding.
-Vital signs are in
the normal
range[1], [2]

2. RR: 26bpm
BP: 100/60mmHg
SpO2: 98%
o At 9:00: The patient is alert and
conscious
V/S taken as follows:
T: 36.5o
C
P: 107bpm
RR: 26bpm
BP: 100/60mmHg
SpO2: 97%
oAt 15:00: The patient is alert and
conscious
V/S are taken as follows
T: 37.3o
C
P: 122bpm
RR: 32bpm
BP: 100/70mmHg
SpO2: 98%

3. 2.
-The patient still
coughs- Phlegms
cough.
- Coughing tends to
increase at midnight
and early in the
morning
- Phlegms are white
and thick, with
amounts of
approximately 3-4
milliliters per
expectorated).
-Phlegm is the
product of the
inflammatory
reaction, which is
secreted in the
alveoli or bronchi.
-Cough is a natural
reflex to keep the
airway “clean”
-The patient still
coughs due to the
inflammatory
reaction that
increases mucus
secretion in the
alveoli, irritating the
respiratory mucosa
- Provide cough
relief for the
patient
- Provide phlegm
reduction for the
patient.
- Provide
instruction for
oropharynx
hygiene
- Assess the severity and frequency
of coughing:
It is a phlegm cough
Frequency: moderate during the
day and increases at midnight and
early in the morning
- Assess phlegm’s texture, and
quantity
- Encourage movement and
positioning.
- Use peppermint oil while awake
and before sleeping time
- Keep the body warm
- Perform chest physiotherapy
- Drink warm liquid to soothe the
throat ( lemon juice with honey)[3]
- House cleaning and vacuuming
-The mother
understands the
issue being guided
-The parents
carried out the
issues being guided
-The state of cough
has been reduced

4. - Instruction for oropharynx
hygiene[4]:
o Brush teeth 3 times per day after
a meal. Brush gently, use an
adapted type of toothbrush
o Cleaning between teeth to
remove plaque.
o Eat a well-balanced diet. Limit
sweets and sugary drinks.
o Use Sodium Chloride 0,9%
solution to wash mouth[5], [6].
3. Mild wheezing at
midnight
Doubts that
wheezing due to
inflammatory
agents irritating
alveoli to produce
mucus to fill and
obstructive the
airway.
Decreased
symptoms for the
patient
-Assess the severity and frequency
of wheezing
-Instruction nasal hygiene with
seawater.
- Monitor the Respiratory rate
- Assess for respiratory distress
signs
- Carry out prescription: Salbutamol
Sulfate (Ventolin Nebules)
-The mother
understands the
issue being guided
-The parents
carried out the
issues being guided
-The state of
wheezing has been
reduced

5. 2,5mg/2,5ml x 3 tubes of solution.
Nebulized. 3
[7], [8]
4. Nausea after eating -Doubts this
phenomenon
occurs when the
lower esophageal
sphincter does not
close properly. The
valve between the
esophagus and
stomach of children
is not strong
enough to prevent
food from stomach
reflux to the
esophagus.
-Doubts that the
patient has nausea
due to side effects
of certain
medication
-Decreased
severity or
elimination of
nausea
-Prevent the risk
of vomiting
-Assess nausea characteristics:
nausea appear after eating
-Position the patient upright while
eating and for 1 to 2 hours
post-meal
-Keep rooms well-ventilated.
-Encourage the patient’s mother to
avoid foods and beverages that are
gastric irritants.
- Instruction for oral hygiene
-Encourage the use of peppermint
oil to massage the abdomen[9]
-Encourage the liquid, soft, and
digestive easily food for the child.
- Monitor the medication’s side
effects.
-The patient has no
nausea after eating
-The mother
understands the
issue being guided
-The parents
carried out the
issues being guided

6. (Cefuroxime –
Antibiotics)
- Explain to the parents about
possible side effects of this
medication.
5. The nose
discharges a small
amount of white
mucus.
The nose
discharges mucus
due to inflammatory
agents irritating
mucosa to produce
mucus
Nose hygiene -Use seawater to hygiene the
nose[5], [6]
-Advised the mother to clean the
house, and avoid the patient's
approach with dust, smoke,...
-Advised the mother to keep the
child warm, often monitoring his
temperature
-The nose has
been good hygiene
-The mother
understands the
issue being guided
-The parents
carried out the
issues being guided
6. The stool is loose -Doubts that the
change of stool
texture in this
patient is due to the
imbalance of fluids
and electrolytes.
-The change in
defecation occurs
when the
- Planning to
improve the state
of digestion for the
patient
- Prevent Fluids
and Electrolytes
imbalanced
-Assess the features of the stool
every day including color, amount,
type, and feeling when defecating.
-Assessing changes in bowel
habits, and bowel sounds.
-The mother
understands the
issue being guided
-The parents
carried out the
issues being guided
-The stool is soft

7. inflammatory
agents affect the
metabolism and
absorption of the
body.
- Doubts that the
change of stool is
due to certain
medications:
antibiotic
- Encourage the patient to increase
fluid intake based on requirements
as tolerated
- Calculate the bilan water
-Advised patients to take the
recommended dose of dietary fiber
for the patient
- Assist the patient in doing physical
activity
-Carry out prescription:
Enterogram (Bacillus clausii) 2
billion cells/gram x 2 packets. Oral.
2 times per day. At 8:00, 14:00
7.
-The patient eats less
than the daily
nutritional
recommendations.
-The patient has not
completely breastfed
- Inappropriate
nutrition
- Lack of
knowledge of the
mother
- The patient’s loss
of appetite due to
Certain
-Improve the
patient’s nutritional
status.
-Assess nutritional
status and prevent
the risk of weight
loss
- Determine the patient’s weight,
height, and BMI
Height: 111cm, weight: 16kg, BMI:
13.0kg/m2
Nutritionals needs
recommendations[10]:
100kcal/kg/day 🡪 700kcal/days
-The mother
understands the
issue being guided
-The parents
carried out the
issues being guided

8. within 6 first months of
life.
-The patient has a
loss of appetite
medications-
antibiotics: Due to
the effects of killing
bacteria, it disrupts
the balance of
intestinal
microflora, reduces
beneficial bacteria,
and promotes the
growth and
invasion of harmful
bacteria.
- Assess the patient’s eating
pattern:
▪ According to her mother, the
patient is breastfeeding based on
her requirements. Each time is
about 100 milliliters.
▪ The patient eats 3 meals per day,
she is eating nutritious porridge
-her parents bought it at the
restaurant. The ingredients of the
porridge changed every day.
▪ Today:
❖ Breakfast: rice, minced pork, and
spinach
❖ Lunch: rice, shrimp, pumpkin,
and carrots
❖ Dinner: rice, salmon, peas,
potatoes
-The mother
planned for the
patient a new
adapted diet
- NRS-2002 – 2
points – Low risk

9. ❖ Snacks: a quarter of banana, 1
box of yogurt, 3 small pieces of
watermelon
❖ Water: 200-300 milliliters.
▪ According to her mother, the
amount for each time is about a
quarter of a bowl.
- Assess the patient’s nutritional risk
using nutritional risk screening
tools. ( NRS-2002) – 2 points –
Low risk
-Encourage the mother to feed the
children with their favorite food
-Advised to choose color food
-Divided the 3 large meals into 6
small meals
- Recommendations[11] :

10. ❖ Continous breastfeeding (should
be the main meal) – the most
important
❖ Vitamin complex ( C, A, B, E, D)
in citrus, berries, broccoli,
carrots, milk, yogurt, eggs,...
❖ High-quality protein such as
beef, pork, fish, and seafood
❖ Colorful vegetables can
randomized in daily meals
❖ Omega-3 fatty acid: fish,...
❖ Foods rich in Zinc and Iron: beef,
peas, potatoes, etc
❖ Water needs in 24 hours:
100mL/kg = 700mL/day[12]

11. -Provide knowledge about
breastfeeding and its effectiveness
in the child’s growth.
- Consider seasoning for patients
with changes in their sense of taste
(no spicy or too hot)
- Provide good oral hygiene and
dentition.
-Encourage home-made than a
restaurant
- Makes the child happy at meal
- Advise a healthier diet for the
mother [13]
8. Prevent Pneumonia
complications and
diarrhea
-Due to the strong
connection
between
Pneumonia and
diarrhea. If
prolonged will lead
Prevent the risk -Monitoring vital signs
-Assess signs of respiratory
distress, pallor, shortness of breath,
vomit
-Encourage the patient to adhere to
treatment.
-Enhanced immunity for the patient
-The mother
understands the
issue being guided
-The parents
carried out the
issues being guided

12. to severe
progression.
-Depends on the
vicious circle of
Pneumonia-Diarrhe
a: prolonged
diarrhea will lead to
reduced immune
function. On the
other side, in the
state of increased
secretion of mucus
of alveoli, the
patient naturally
swallows it; the
bacteria in the
mucus will emit
toxins and irritate
the bowel.
-Pneumonia may
cause many
complications if not
-Planning an adapted diet for the
patient
-Assess the water intake – outtake
-Assess the balance of water and
electrolytes
-Encourage good hygiene: hand,
oral, nasal,... with sanitizers
-Assess bowel habits, defecation
-Advised the patient's father to quit
smoking
-Encourage the parent to clean the
house, and avoid dirt and fusty.
-Carry out prescription:
● Cefuroxim (Cefuroxime 750)
750mg x 3 bottles.
Intravenous. Divided by 2
times, each time 0.5 bottles.
At 14:00, 20:00
● Salbutamol Sulfate (Ventolin
Nebules) 2,5mg/2,5ml x 3
tubes of solution. Nebulized.
-The parents
understand the
importance of
preventing
complications.
-The parents
understand the
importance of
taking good care of
the child

13. taken care of such
as Sepsis, pleural
effusion,[14].
3 times per day. At 8:00,
14:00, 20:00
● Enterogram ( Bacillus clausii)
2 billion cells/gram x 2
packets. Oral. 2 times per
day. At 8:00, 14:00
[15]
9. Health education
for the patient and his
mother.
Her father smokes.
-Lack of knowledge
of disease
prevention
-Lack of knowledge
of nutritional care
-Lack of knowledge
for self-care of the
mother to give a
high-quality of
breastmilk
-Lack of knowledge
about weaning time
for the child
Health education -Instruction on how to monitor the
child at home
-Advised for hand hygiene with
soap or sanitizers, oral and nasal
hygiene with seawater
-Instruction on how to plan a diet for
the child
-Advised to wear the mask in public
-Advised for house cleaning
-Advised the father to quit smoking,
and show him the harm of smoking
-Advised the mother to have
healthier nutrition.
-The mother
understands the
issue being guided
-The parents
carried out the
issues being guided
-The parents
understand the
importance of
taking good care of
the child
-The father
understands the

14. -The father's lack of
knowledge about
smoking harmful
-Advised an adapted diet for the
patient
-Encourage home-made meals
rather than buying them at the
restaurant
[16]
harm of smoking,
and quit smoking
Reference:
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