Nursing Care Plan for Pediatric Care and SBAR Notes (Other (Not Listed) Sample)

Nursing Care Plan for Pediatric Care and SBAR Notes Student Name Institutional Affiliation Course Code Instructor Date Situation Patient: J.S, a 6-month-old female infant admitted to the pediatric unit Background Primary Nursing Diagnosis: Deficient Fluid Volume related to acute gastroenteritis fluid losses. Assessment: J.S. presents with vital sign abnormalities; physical exam findings and lab values show consistent fluid volume deficit, including tachycardia, tachypnea, fever, poor skin turgor, dry mucous membranes, and elevated BUN/Cr. She has a 3-day history of diarrhoea, vomiting, and poor intake resulting in 0.5kg weight loss, signs of clinical dehydration, and inadequate urine output. Expected Outcome: * J.S. will achieve consistently positive fluid balance with urine output of 2 ml/kg/hour sustained for 24 hours prior to discharge (Willacy, 2020). * J.S.'s skin turgor, mucous membranes, and fontanel will return to normal limits Nursing Recommendations: * Administer intravenous fluids such as 0.9% normal saline with the rate titrated to replace measured ongoing losses and replete the deficit. Fluid boluses may be needed until urine output consistency improves (Replacement Fluid Therapy, 2017). * Assess intake and outputs on an hourly basis to closely monitor hydration status. Output should be 2 ml/kg/hr to indicate adequate hydration (Willacy, 2020). * Gently encourage oral fluid intake with small, frequent feedings of 10mL per kg of recommended rehydration solutions such as Pedialyte or an oral rehydration salt mixture at first (Willacy, 2020), transitioning to bland foods like bananas, rice, applesauce, or toast and clear liquids as tolerated to support continued hydration maintenance enterally. * Continue daily body weight checks along with assessing skin turgor and mucous membranes to evaluate trends in fluid balance status. Compare physical examination findings of hydration status indicators against the patient's normal baseline parameters. Promptly notify the provider of any positive or negative deviations detected. * Educate the patient and family on recognizing signs and symptoms of dehydration at home following discharge. Specifically, instruct them on maintaining adequate fluid intake and restoration in the event of future gastroenteritis occurrences, emphasizing oral rehydration therapy using recommended fluids and electrolyte solutions (“Pediatric Gastroenteritis in Emergency Medicine: Practice Essentials, Background, Pathophysiology,” 2020). Evaluation: J.S. achieved weight gain, and her urine output consistency has been 2 mL/kg/hr for 18 hours. Her mucous membranes are moist again, and her skin turgor has normalized. She continues tolerating oral feeds without difficulty. J.S.'s mother can correctly describe signs of dehydration to monitor for at home and verbalize methods to prevent dehydration through increased fluid intake. Background Secondary Diagnosis: Risk for acute pain related to peripheral IV insertion Assessment: J.S. has a newly inserted 24-gauge catheter in her left hand for fluid administration (4 Steps to Owning the Infant IV, 2022). This creates a risk for phlebitis and infiltration, leading to localized swelling, erythema, and discomfort at the site (Kaur et al., 2019). Expected Outcome: * J.S. will remain free of any signs or symptoms of IV infiltration or phlebitis, including edema, redness, streaking, palpable venous cord, or tenderness at the catheter site. Nursing Recommendations: * Complete and document assessments of the IV insertion site once per shift for any swelling, leakage, redness, or palpable venous cord per hospital policy and at the start/end of infusion therapy (Kaur et al., 2019). * Rotate the catheter site per hospital standards whenever a new IV line is placed to prevent repeated injury in th...