hi, tina 24!
wow! i don't know how i missed your post on this. i usually do a search for posts on care plans
and must have missed this one. i'm aware that your care plan has probably been completed and turned in by now. however, in the interest of others who might find this helpful i am posting a reply to your question. just a suggestion, however, that any students looking for help with care plans to please also post in the student nursing forums as you are more likely to get responses to questions on care plans there:
when you are starting a care plan you always follow the nursing process. the first step is to collect your assessment data. this includes not only the physical assessment that you perform on the patient, but also the information that you collect from the chart. review the doctor's history and physical, any consultant's reports, labwork, x-ray results, evaluations by dietary or physical therapy and the nursing admission assessment. copy down any and all abnormal data. all that data is usable by you in formulating nursing diagnoses for your patient.
the next step is to put the list of the abnormal data items in front of you. this will include signs and symptoms, abnormal lab values, and other things. this is, as i said above, all usable data. before nanda came along, we referred to these things as "problems". what nanda has done has been to take some of the problems and grouped them together and labeled them as nursing diagnoses. there are 172 of them and each has been defined and has a list of symptoms, nanda calls them defining characteristics, we can call them abnormal data. a nursing diagnosis is defined by nanda just as a medical diagnosis has a definition. so, when you assign a nursing diagnosis to a patient, we all know what it means and what is likely to be going on with the patient.
the other aspect of choosing a nursing diagnosis is determining what is causing this nursing diagnosis. nanda calls them related factors. again, each nursing diagnosis has specific related factors that nanda has assigned to it. it would be a very good idea to obtain a handbook of nursing diagnoses. these kinds of books usually list all 172 nursing diagnoses, define each one and lists the official nanda defining characteristics and related factors. they often also list nursing outcomes and nursing interventions with rationales as well. these are all nanda approved. this is what is being taught in most of today's nursing schools
once you've established nursing diagnoses, the remainder of your care plan which is the goals, outcomes and nursing interventions are based on the defining characteristics (symptoms) that you determined were the reason you chose certain nursing diagnoses in the first place.
for a patient with pyelonephritis and infection, you need to start by listing the symptoms that your patient is having. you should have gotten some information from the patient's h&p and labwork. you need to list the child's actual temperatures on your care plan. you also want to know what the symptoms of pyelonephritis are. you can look this up in a pathophysiology book (you probably need to include this on your care plan anyway) or in a nursing textbook. here is a website that i like to use that gives you thumbnail views of what the disease is, causes, signs and symptoms, and medical management. you need to know this information to help with the patient's care.
knowing nothing else about the patient except her medical disease and that she is 3 years old, has a fever, information you supplied, i am also going to assume she has these other symptoms as well:
- flank pain
- dysuria, frequency or urgency
from just those i can develop a couple of nursing diagnoses (in order of priority). i've included links to online nursing diagnosis and nursing intervention information from the gulanick and ackley/ladwig care plan constructor sites when ever it was possible to get that information:
- impaired urinary elimination r/t irritation of urinary tract aeb dysuria, frequency or urgency
- nausea r/t swelling of kidney structures aeb vomiting, gagging or increased salivation (http://www1.us.elsevierhealth.com/ev...ex.cfm?plan=32)
- acute pain r/t inflammation and irritation of the urinary track aeb flank pain and patient's verbal complaints of pain (http://www1.us.elsevierhealth.com/me...ex.cfm?plan=40)
- impaired comfort r/t fever aeb hot, flushed skin and/or diaphoresis
- activity intolerance r/t bedrest and weakness aeb restlessness (http://www1.us.elsevierhealth.com/me...ex.cfm?plan=01) (http://www1.us.elsevierhealth.com/ev...dex.cfm?plan=1)
- ineffective health maintenance r/t care deficit of parent(s) aeb parents expressed interest in learning to recognize and deal with signs and symptoms of renal and urinary problems with child. (http://www1.us.elsevierhealth.com/me...ex.cfm?plan=27) (http://www1.us.elsevierhealth.com/ev...ex.cfm?plan=24)
- risk for deficient fluid volume r/t failure to consume adequate fluid (http://www1.us.elsevierhealth.com/me...ex.cfm?plan=21) (http://www1.us.elsevierhealth.com/ev...ex.cfm?plan=20), or risk for excess fluid volume r/t compromised condition of remaining kidney (http://www1.us.elsevierhealth.com/me...ex.cfm?plan=22) (http://www1.us.elsevierhealth.com/ev...ex.cfm?plan=21)
now, your nursing interventions will be listed under the various nursing diagnoses. you will address strategies specific to the age of a toddler in your nursing interventions taking into account her developmental level.
here is an explanation about the difference between goals and outcomes: http://allnurses.com/forums/1901960-post10.html
was the care plan you developed anything like this? what did you end up using for your nursing diagnoses? writing care plans is one of the most complex activities that you will learn as a nursing student. they may seem difficult at first, but you have to keep working at it. the care plans you develop for patients as a student are to help you learn to think critically as well as to learn how medical diseases are treated and what nursing care should be offered. it will take writing many care plans before you get the hang of it. don't be discouraged by those who might make you feel that you are not working up to par on this skill. it is a hard skill to learn!
here are two threads on allnurses where you can get more information and web links to sample care plans and case studies to look at:
hope to see you on the nursing student forums. welcome to allnurses!