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Care Map 

 

 

List all subjective and objective assessment information place the findings in the assessment data box below.
Based upon assessment information, identify and prioritize the patient’s top 3 Nursing Diagnoses. List one Nursing Diagnosis in each of the columns on slide 3 and document the relevant assessment information that supports the identified diagnosis.
Formulate 1 SMART goal for each diagnosis.
Identify 3 important nursing interventions with rationales for each diagnosis.  The interventions should address the diagnosis and should be specific to the patient.

Case Study 

The nurse is caring for a 3-year-old pediatric client who has been admitted to the hospital for care secondary to respiratory syncytial virus (RSV) infection and pneumonia. The client is learning to cover their cough and sneeze but does not do it routinely. The child’s mother is with the client most of the time. The client demonstrates fear of the nursing staff by crying when they enter with a mask and gown to provide care for the child, making it difficult to complete assessments of the client’s condition. The mother has requested that staff do not wear masks when entering the room to prevent the child from being fearful. The child demonstrates some respiratory difficulty with mild intercostal retractions and respiratory rate of 32. Other vital signs include HR 110, Temp 101.2°F. The child is receiving antibiotics intravenously, nebulized breathing treatments, and antipyretics. This is the child’s first hospitalization.

 

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SCIENCE
HEALTH SCIENCE
NURSING
NSG 110

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