SITUATION FOR ELIMINATION ROUND OF NCP MAKING CONTEST:

R. B. a four year old restless male child is presented with high-grade fever with accompanying signs and symptoms of vomiting and headache for the past 4 days. The client looks pale and his skin is dry. The mother reported that she observed R.B. having coffee-ground color stool with accompanying epigastric pain. The client gave 3-4 from Wong-Baker’s Pain Scale of 0-5 (no pain - worst possible pain). Upon physical examination, the child’s extremities are cold and pulse is thready and weak. Lung fields are clear upon auscultation. Liver is 3cm below the costal margin and spleen is not palpable. Tourniquet test is negative. Capillary refill is 5 seconds.

Upon interview, the nurse found out that they live in a squatter’s area where there are bunch of trashes and weary tires around which are good breeding sites for mosquitoes.

Vital signs and Lab findings:

Temp: 38.9 degrees centigrade

PR : 150 cpm

RR: 36 cpm

BP: 60/50

Hemoglobin: 80 g/L

Hematocrit: 0.60

Platelet Count: 90 x 10 ⁹/L

Neutrophils: 74 %

Eosinophils: 4 %

Lymphocytes: 30 %

Monocytes: 11 %

Basophil: 0.2 %

Serum sodium: 132 meQ/L

Serum potassium: 5.6 meQ/L

Out of the given situation make a hand written or typewritten NURSING CARE PLAN of your prioritized problem. One entry per section only.

Deadline: November  9, 2007

Note: please write a short justification on why you have prioritized your problem

Format:

         Section:  _____

         President:  _________________ Contact Number:_____________

Nursing Dx and Cues	Analysis	Goals and Objectives	Interventions	Rationale	Evaluation

Justification:          

__________________________________________________________________________________

__________________________________________________________________________________

Approved by:

Prof. Taha Jejin Nonog

Prof. Terrence Ranjo

Prof. Rey Aldus Alejandre

Prof. Ritchie Rueda