Hi all,

I'm having trouble with a pediatric care plan (it's the first one I've done in the course).

Some background info on the patient: 3 y/o female with acute myeloid leukemia and trisomy 21. She is developmentally delayed and does not speak. Her parents/other family are not present so they cannot speak for her. She only interacts with staff.

The diagnoses that I am brainstorming (this list is not complete - these are just the ones I'm having trouble with):

-risk for infection

-ineffective protection r/t thrombocytopenia

I'm having trouble with subjective information for the risk for infection and ineffective protection diagnoses. We have always been taught that the subjective information generally has to be in quotes since it's coming from the patient/family. Since this patient is not able to speak and family is not there to speak for her I'm a bit stumped. Can someone point me in the right direction? Is it appropriate to state that there are none since the patient and family can't say anything?

Thanks!!

You have told me what she has NOT what she needs. What care plan resource do you use? NANDA I book of ND would have the interventions you need.

Ineffective protection: Decrease in the ability to guard self (and in this case, for the caregivers to guard him ...) from internal or external threats such as illness or injury . Defining characteristics : deficient immunity, disorientation, immobility, impaired healing, neurosensory alteration, pressure ulcers, weakness. Related (to) factors: Inadequate nutrition; pharmaceutical agents (e.g., corticosteroids, chemo, and others)

ow what "proof" do you have? http://www.pterrywave.com/nursing/care%20plans/25.aspx

If the child can not speak they have communication issues that are impaired.

If she is developmentally delayed she had speak she has issues with growth and development

What about family stress? Family coping?

Care plans are all about the assessment what is your assessment? According to Maslows what are this babies needs and how does illness affect children? You do not need a verbal response to seek information.

Care plans are all about the assessment...of the patient. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE from our Daytonite

1. Assessment
   (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
   
2. Determination of the patient's problem(s)/nursing diagnosis
   (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
   
   
3. Planning
   (write measurable goals/outcomes and nursing interventions)
   
   
4. Implementation
   (initiate the care plan)
   
   
5. Evaluation
   (determine if goals/outcomes have been met)
   
   

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1.

Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Another member GrnTea say this best......

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else.

Risk/for self harm r/t developmental delays; lack of supervision?

You have told me what she has NOT what she needs. What care plan resource do you use? NANDA I book of ND would have the interventions you need.

Ineffective protection: Decrease in the ability to guard self (and in this case, for the caregivers to guard him ...) from internal or external threats such as illness or injury . Defining characteristics : deficient immunity, disorientation, immobility, impaired healing, neurosensory alteration, pressure ulcers, weakness. Related (to) factors: Inadequate nutrition; pharmaceutical agents (e.g., corticosteroids, chemo, and others)

ow what "proof" do you have? http://www.pterrywave.com/nursing/care%20plans/25.aspx

If the child can not speak they have communication issues that are impaired.

If she is developmentally delayed she had speak she has issues with growth and development

What about family stress? Family coping?

Care plans are all about the assessment what is your assessment? According to Maslows what are this babies needs and how does illness affect children? You do not need a verbal response to seek information.

For my diagnosis of ineffective protection. I was actually going along the lines of being unprotected from potential bleeding due to thrombocytopenia. My proof is in her lab values. I already have diagnoses related to her communication issues and family processes but I feel that this issue also needs to be addressed. I was not referring to the lack of caregivers in that respect. I'm just having trouble with thinking about subjective information to support this. I use the Ackley Nursing Diagnosis Handbook because my school required it. I would love to add the NANDA book that you recommend to my collection but I can't buy any new books now lights, food and a roof over my head are more important now.

Like I said the definition of Ineffective protection: Is the

Decrease in the ability to guard self (and in this case, for the caregivers to guard him ...) from internal or external threats such as illness or injury .

Defining characteristics : deficient immunity, disorientation, immobility, impaired healing, neurosensory alteration, pressure ulcers, weakness.

Related (to) factors: Inadequate nutrition; pharmaceutical agents (e.g., corticosteroids, chemo, and others)

Now what "proof" do you have? Ineffective Protection, inadequate nutrition, impairment of primary defenses and medical interventions

Thrombocytopenia would be more risk for bleeding.

As I have already said I cannot help you without an assessment. Care plans are all about the patient and the patients assessment and in this case the parents statements/observation. It sounds like you have made the common mistake of picking the diagnosis first and trying to retro fit the patient into it. You need to focus on the information at hand to help you decide what the patient needs. NANDA I can be rented from amazon for $17.00 and free shipping for students.

But I cannot help without an assessment.

Like I said the definition of Ineffective protection: Is the Decrease in the ability to guard self (and in this case for the caregivers to guard him ...) from internal or external threats such as illness or injury . Defining characteristics : deficient immunity, disorientation, immobility, impaired healing, neurosensory alteration, pressure ulcers, weakness. Related (to) factors: Inadequate nutrition; pharmaceutical agents (e.g., corticosteroids, chemo, and others) Now what "proof" do you have? Ineffective Protection, inadequate nutrition, impairment of primary defenses and medical interventions Thrombocytopenia would be more risk for bleeding. As I have already said I cannot help you without an assessment. Care plans are all about the patient and the patients assessment and in this case the parents statements/observation. It sounds like you have made the common mistake of picking the diagnosis first and trying to retro fit the patient into it. You need to focus on the information at hand to help you decide what the patient needs. NANDA I can be rented from amazon for $17.00 and free shipping for students. But I cannot help without an assessment.

I ended up not using this diagnosis because I don't seem to have enough information. Maybe I didn't do a thorough enough assessment but all of my classmates and my instructor agreed that it is difficult to obtain subjective information in this case. We all had this patient at one point and my instructor actually works on the unit so she has a ton of experience with the patient. Thanks for your assistance!

It is hard to get subjective on an infant......for the future....here are some brain sheets from another member Daytonite (RIP)that might help.

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

Thanks esme!