Question
I need three nursing care plan for this scenario Background Information: Mary is a 12 month...
Answers
The nursing care plan should be formed on the basis of priority according to the assessment done. Hence it is formed on the basis of complaints reported.
The three care plans made on the basis of the immediate complaints are as follow:
1. Hyperthermia related to inflammatory pathological process as evidenced by increase in the body temperature.
- assess the temperature of the infant every 2hrly.
- identify the source of increase in body temperature.
- remove the heavy clothing wrapped around the infant and put a thin cloth to cover her up.
- if required provide sponge bath which will help in reduction of the fever.
2. Imbalanced fluid volume or fluid volume deficit related to vomiting and decreased fluid intake as evidenced by dehydration.
- assess the level of dehydration in the infant.
- wet the lips with the water in order to make the mouth rehydrated.
- try to provide liquid diet in a very small amount to check if the infant is able to digest or hold the liquid .
- if the infant is able to take the liquid diet then provide in a very small amount and very frequently.
- but if the infant is not able to digest the liquid diet then immediate i.v should be started in order to rehydrate her.
3. Fatigue related to dehydration as evidenced by pathetic state of the infant.
- assess the level of lathergy in the infant.
- provide the infant with fluid containing electrolyte.
- assess the condition of the infant frequently until she regains her normal function.
- provide proper rest and sleep to the infant.
- provide comfortable position and comfort devices as well as proper well ventilated room in order to provide good sleep.
- check if the baby is able to regain her normal activity after providing interventions, if not then re plan for the same diagnosis.