FORMULATE A NURSING CARE PLAN BASED ON THE CASE SCENARIO. Identify 1 actual and 1 potential problem

FORMULATE A NURSING CARE PLAN BASED ON THE CASE SCENARIO. Identify 1 actual and 1 potential problem based on your assessment, total of 2 NCP.  Minimum of 5 Nursing Implementation or intervention each NCP.  You are now on duty at Pediatric Ward of Lorma Medical Center for a 7am-3pm shift. Ms. Curtis-Smith then oriented you with the physical set up of the unit as well as the staff nurses. She then instructed the group to join the endorsement and rounds as well. After the rounds, each student was given their own patient. You were not assigned initially to any patient but you will be in-charge of first admission.  At around 8:12am, Nurse Rick, SNOD at Pediatric ward received a call from Emergency Room regarding patient for admission. The incoming patient is a 3 year old, male, with presenting complaint of fever and vomiting. Your CI then instructed you to check and prepare the bed for the patient. At 8:22am, the client was wheeled in at Room 325 per gurney, accompanied by parents and by Nurse Gav, ER staff. You and your CI went to receive the patient as well as to receive endorsement. As per endorsement, patient is Kai Araneta, 3/yo male, with an initial diagnosis of t/c AGE (Acute Gastroenteritis). He is under the care of Dr. Kim, aPediatrician. Parents are Mr. Gabby Araneta and Mrs. Sharon Araneta. There were no allergies as claimed by parents. Weight and height were taken at ER and recorded as follows: Height: 37.5 inches Weight: 15kg. Nurse Gav also endorsed the following: (1) Patient is receiving a venoclysis of D5 IMB 500mL @ 60ugtts, (2) To start the following meds upon admission: Paracetamol (Tempra) 250mg/5ml 5ml every 4 hours PRN for fever, Metoclopramide (Plasil) 5mg/5ml 5ml TID for vomiting, Oral Rehydration Salts (Hydrite) 1 sachet in 200ml water, to give at every bouts of vomiting or watery stool ; (3) Monitor bouts of vomiting and/or watery stools ;(5) Watch out for signs of dehydration and refer ASAP; (4) May start diet for age or BRAT diet as tolerated; (5) Monitor VS and I and O every 4 hours; (6) TSB as needed, (7) Do CBC and platelet now (done at ER), (8) Request for UA and FA once available. Upon receiving endorsement, VS was checked and recorded at 8:30am, as follows: BP 80/50mmHg PR 110bpm RR 22 breaths/min O2SAT 98% Temperature 37.8 degree Celsius. Baby Kai is not crying but constantly clinging to her mother. Assessment was continued with the guidance of your Clinical Instructor.  After interacting with the child and his parents, you then continued your assessment and history taking. As a student nurse, you know that accurate data of the patient is important in giving care to them. Having knowledge on growth and development milestones, the following observations were noted. Kai can already walk and run around the room well, according to the mother, he sometimes fall from their stairs because he often walks up and down. . He started to walk according to the parents when he was about 10months old; he started from holding on to furniture to steady himself until he was able to do it alone. He often plays alone on his bike and toy cars. He can also eat well alone using spoon and fork. He is a “picky eater” and often prefers finger foods like chicken nuggets and hotdogs. He is not fond of fruits and vegetables and only consumes formula milk at times. He still sticks to his routines according to the mother like taking a bath before naps and bedtime. He also throws tantrums when things don’t go his way.  During your interaction with the patient, you noticed that he still has unclear speech; he can’t say his name or age clearly, but makes babbling noises. When he sees her parents, Kai waves her arms and legs to show her excitement, but he is nervous around strangers. He often cries when her parents leave the room. As you continue your assessment, you observed that he can put on his shirt alone and even do his buttons. You offered him toys to divert his attention and he picked tower blocks and played with it. He already developed his daytime bladder control according to the mother but still has to wear diapers during night time. After the assessment, you thanked the patient and his carers and instructed them to use the call bell as needed. At around 10:30am, you and your Clinical Instructor went back to the patient’s room to administer his medicines as well as to instruct the parents regarding orders of the physician like the child’s diet and other pertinent orders. Health teachings were also imparted to both the patient and his carers as a part of your Discharge Plan. FORMAT: ASSESSMENTNURSING DIAGNOSISPLANNINGIMPLEMENTATIONRATIONALEEVALUATIONSUBJECTIVE:  INDEPENDENT:      DEPENDENT: OBJECTIVE:   COLLABORATIVE:     Example of a Nursing Care Plan:ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION SubjectiveRisk for imbalanced After 48 hours of Independent: GOAL MET. After 48 “I’m not sure if my baby isnutrition related to intervention, the . Encourage mother to breastfeed as . 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