Czarina C.

Tuazon 2011-62909 Marc Lhorenz Motillo

May 13, 2015

Ineffective Airway Clearance r/t cervical cyst obstruction

Impaired gas exchange
Background Information
Cues
Interventions
NIC Airway Management
State in which a client
Subjective:
Offer oxygen therapy if permitted.
experiences inability to
Cyst was present at
Encouraged patient to deep breathe
clear secretions or
birth and continued to
every 2 hours while awake. Assist
obstructions from the
grow after vaccination
with respiratory treatments, such as
respiratory tract to
Objective:
spirometry.
maintain a clear airway.
RR: 28
Assist client to maintain a
Children have smaller
O2 Sat: 86%
comfortable position to facilitate
airways than adults
breathing by elevating the head of
Cyst is movable, firm,
which is prone to
bed, leaning on over-bed table, or
not attached to skin,
occlusion/obstruction.
sitting on edge of bed.
approx. 2 inches big,
Aggravating this is the

Provide supplemental humidification,

painless, non-tender
cystic hygroma located
located at the left side
such as humidifier.
at the left side of the
of the neck with bluish
neck.
veins dilated beneath
Imbalanced Nutrition: Less than body requirements r/t inadequate recommended dietary intake
secondary to lack of knowledge of caregiver
Ineffective Tissue Perfusion
Background Information
Cues
Interventions
NIC Nutrition Therapy
Intake of nutrients
Subjective:
Review nutritional history, including
insufficient to meet
No history of bleeding
food preferences.
metabolic needs
or blood loss
Observe and record clients food
Decrease in blood
Stopped being
intake.
circulation to the
breastfed at one month Weigh periodically as appropriate,
periphery that may
drinks 7 glasses of
such as weekly.
compromise health
bearbrand milk (3
Recommend small, frequent meals
Children have higher
scoops) and 1 glass of
and between-meal nourishment.
metabolic demands for
water per day
Suggest diet rich in iron and vitamin
iron, especially those
consumes rice per
B12
with chronic illnesses
meal usual meals are Have client record and report
fried bangus, fishes
occurrence of nausea or vomiting,
which is he shares with
flatus, and other related symptoms,
caregiver
such as irritability or impaired
took tiki-tiki for a year
memory.
sleeps from 9pm to
Encourage or assist with good oral
4am and naps for 3
hygiene before and after meals; use
hours
soft-bristled toothbrush for gentle
Objective:
brushing.
10.8kg normal
Provide dilute, alcohol-free
PR: 74
mouthwash if oral mucosa is
ulcerated.
(+) pale conjunctiva
Consult with a dietician
O2 Sat: 86%
Recommended iron
intake is 7mg
hgb: 131 L, MCV: 76.9
L, MCH 25.2 L
indicative of iron

Czarina C. Tuazon 2011-62909 Marc Lhorenz Motillo

deficiency anemia
Risk for Impaired Physical Mobility
Background Information
Cues
At risk of experiencing
insufficient physiological
or psychological energy to
endure or complete
required or desired daily
activities

Subjective:
Congenital cystic
hygroma reported to
be increasing in size
Reported scheduled for
surgery on 5/13/15
Objective:
16 months old
Cyst is movable, firm,
not attached to skin,
approx. 2 inches big,
painless, non-tender
located at the left side
of the neck with bluish
veins dilated beneath

May 13, 2015

Interventions
NIC Bed Rest Care
Facilitate teaching for surgery
setting via role play and pamphlet
(EBP)
Position client to avoid skin and
tissue pressure damage. Turn at
regular intervals, and make small
position changes between turns.
Provide meticulous skin care,
massaging with emollients.
Remove wet linen and clothing, and
keep bedding free of wrinkles.
Monitor urinary output. Note color
and odor of urine. Assist with
bladder retraining when appropriate.
Provide fluids within individual
tolerance (that is, regarding
neurological and cardiac concerns),
as indicated.
Monitor bowel elimination and
provide for or assist with a regular
bowel routine. Check for impacted
stool; use digital stimulation, as
indicated. Sit client upright on
commode or stool at regular
intervals. Add fiber, bulk, and fruit
juice to diet, as appropriate.
Inspect for localized tenderness,
redness, skin warmth, muscle
tension, or ropy veins in calves of
legs. Observe for sudden dyspnea,
tachypnea, fever, respiratory
distress, and chest pain.

EBP: Bolinger, K., et al. (2012). Ambulatory Surgical Services/Preoperative Education/Knowledge

Retention/Best.
Cincinnati Childrens Hospital Medical Center. Retrieved on May 13, 2015 from:
http://www.cincinnatichildrens.org/WorkArea/DownloadAsset.aspx?id=99566