help with care plan vented/trached 8 month old baby

[taf92]

I'm writing a careplan/case study on an 8 month old baby at long-term care facility for kids. My patient was an 8 month old who is on a vent and trached. His diagnosis was bronchopulmonary dysplasia/ chronic respiratory failure. He was born full term but this all stemmed from meconium aspiration syndrome. He also has a Gtube and is not being fed by mouth at all because of swallowing problems.

I thought I'd have such an easy time picking the nursing diagnosis priorities here but it's harder than expected.

Here's what I've got so far. I'd really appreciate some suggestions :)

Impaired Gas Exchange R/T meconium aspiration and poorly functioning lungs, as evidenced by bronchopulmonary dysplasia and pulmonary hypertension

Ineffective tissue perfusion

Imbalanced nutrition: less than body requirements r/t poor feeding behavior/poor swallow and G-tube feedings

[LadyFree28, BSN, LPN, RN]

What was your assessment?

Your initial presentation was about your pts medical history.

What did your assessment present for you? What medications is this pt on? Are there potential/actual issues for your pt with a trach/vent?

[JustBeachyNurse, LPN]

Do you have a NANDA-I 2012-2014 book?

[Episteme]

Guess I have a similar set of queries. You want to dx the kid with "impaired gas exchange". OK. What is his %sat and what % of oxygen is he breathing? I would suggest you can't use that dx unless, the gas exchange is really impaired. And do you have any evidence that the kid is not blowing off enough CO2?

But that's not so much what struck me in your post. Aren't you supposed to write a nursing diagnosis and plan care for the kid you cared for? You didn't care for the newborn who aspirated meconium.

So I'm confused.

[taf92]

I forgot to include the problem with the nursing diagnoses that I thought were good. O2 sat was good (96), respiration rate within normal limits, heart rate a little high at 178bpm. He did have some rhonchi and wheezes in both lungs.

He was in the facility for vent weaning but all 3 times they began the weaning process he was not taking it well at all and they had to start from scratch.

He had also had his GT placed a few days prior so he was there for feeding therapy. The surgical site looked good, no sign of infection or anything like that. He was tolerating feeds well.

[taf92]

I also noticed that definitely has some developmental delays. At almost 9 months old isn't able to sit up at all without complete support and he cannot get into a sitting position on his own. He also is not able to eat or drink anything by mouth because of his history of aspiration and failed swallow evaluations.

[JustBeachyNurse, LPN]

Meconium aspiration is patient history and would be a part of a postnatal diagnosis not part of a care plan of an 8month old. What is your current assessment data

[mrsboots87]

Also, don't just focus on the assessments around his trach and g tube. What is his functional status ( I know this sounds silly because he is 8 mos old)? What about skin integrity? Does he have edema? AROM/PROM? You are not "picking" a diagnoses. You are assessing your patient and planning care around the nursing diagnoses you identify from your assessment. Take away all the medical history. What is your patient experiencing now? How is the patient responding to current treatment? The medical history matters, but only in that it will help guide your focused assessment and help you to gauge any improvement or decline. Your diagnoses sound like you are finding a diagnoses that matches what you would expect to find on initial assessment of medical diagnosing. Not what is occurring now. Throw away the past and look purely at your assessment data and identify the abnormal findings. Then use a nanda book to find the diagnoses that fits your defining characteristics.