Quote from Jennifer_SN2013
Thank you all so much for your help! Honestly, we only had one day to be on this floor with our patients and by the time I had gotten there he was pretty much ready for discharge. I have never had a pediatric patient before, or been required to do a concept map on someone with so little data. I looked in his chart for any background information, reason for admittance but there was nothing! He did have IV fluids 0.9 NS, and the IV antibiotic but I did not find any reason for admitting him to the hospital. It was my instructors guidance that led me to impaired gas exchange, and possibly due to the amount of swelling in the throat. They had my patient NPO at one time, I think they were going to possibly drain any fluid collection there was, however; there was no fluid collection. I am in my last semester and will graduate in May. Also, my patient is Hispanic but speaks English very well. It was the father who did not speak it very well. So I am going to include in my care plan Impaired Verbal Communication, but is it ok to focus on the father for this diagnosis? I really want to do well, and I am already well into reality shock of nursing! I want to be as prepared as I can and so I thank you all for helping me!
No H&P? No ED record? No nursing admit record? Nothing in the MD progress notes?
I don't see impaired gas exchange at all....NANDA I definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane
Abnormal arterial blood gases; abnormal arterial pH; abnormal breathing (e.g., rate, rhythm, depth); abnormal skin color (e.g., pale, dusky); confusion; cyanosis; decreased carbon dioxide; diaphoresis; dyspnea; headache upon awakening; hypercapnia; hypoxemia; hypoxia; irritability; nasal flaring; restlessness, somnolence; tachycardia; visual disturbances
Related Factors (r/t)
Ventilation-perfusion imbalance; alveolar-capillary membrane changes
Strep throat causes none of those.
Impaired swallowing? Yes.
Impaired oral mucous membranes? Yes.
Ineffective Airway clearance....(Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway
impaired gas exchange? No.
And yes, especially in peds, the inclusion of the parent IS important.
Here are some sheets to help you organize/structure your information before or after graduation.....affectionately called brain sheets
1 patient float.doc
5 pt. shift.doc
day sheet 2 doc.doc
critical thinking flow sheet for nursing students
student clinical report sheet for one patient