Question

Nursing care plan for: Chapter 49: Nursing Care of the Child With an Endocrine Disorder 1. Jalissa Twyman, 8 years old, was admitted to the pediatric intensive care unit with a closed head trauma after being involved in a bicycle/motor vehicle accident. Jalissa is unconscious. The nurses caring for Jalissa document a weight loss of 1.82 kg over a 24-hour period, decreased skin turgor, and dry mucous membranes. Urine output for the same 24-hour period is 3.5 L/m2. (Learning Objectives 1, 2, 3, 4, 5, and 7)

Answer 1

Answer :

Nursing care plan :

1. Impaired level of consciousness related to motor vehicle accident as evidenced by lack of response for EMV ( eye, motor, verbal stimuli) or Glasgow coma scale.

Interventions :

* provide comfortable position ,that one head end elevation to avoid aspiration.

* provide mouth gag or tongue depressor to avoid tongue bite.

* clear the secretions with suction tube.

* provide supportive ventilation by ventilator.

* change position second hourly to avoid bedsores.

2. Imbalanced nutrition less than body requirements related to poor intake of food as evidenced by unconsciousness.

Interventions :

* assess weight of the child daily.

* insert intravenous catheter and provide intravenous fluids and total parental nutrition to improve nutrientional status and to gain weight of the baby.

* insert nasogastric tube and administer no feedings according to the nutritional needs of the baby.

* use sterile techniques to avoid getting infections.