nursing care plan: measles

  1. please help me in creating a nursing care plan with these data:

    10 year old with measles:

    clinical signs:
    -Koplik's spots
    -difficulty in breathing

    Vital signs:

    temp: 39 C
    BP: 100/60
    RR: 35
    PR: 98
  2. Visit maely profile page

    About maely

    Joined: Sep '07; Posts: 8


  3. by   june2009
    Always go for ABCs. If they are having trouble breathing, try ineffective breathing pattern. If it's because of secretions, try ineffective airway clearance or impaired gas exchange.
  4. by   maely
    what can be the nursing diagnosis to the client?
  5. by   june2009
    I'm not sure what you mean.
  6. by   maely
    from the given data, what can be the nursing diagnosis of the nurse to the patient? (assuming that we don't know yet the disease which is measles)

  7. by   Daytonite
    Quote from maely
    from the given data, what can be the nursing diagnosis of the nurse to the patient? (assuming that we don't know yet the disease which is measles)

    doctors base their medical diagnoses on symptoms that a patient has after they perform a physical examination, review the patient's medical history, perform tests and then evaluate the results. nurses do not necessarily need to know the medical diagnosis to treat the patient. nurses base their nursing diagnoses on
    • most importantly
      • a physical assessment of the patient
      • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living)
    • data that they collect from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
    the data you have provided us with are:
    • rashes - you need to minimally assess the location and type of rash
      • location
        • trunk, extremities, palms of hands or feet, face, groin, antecube or popliteal spaces, extensor surfaces of elbows and knees, shins
      • type
        • macular, papular, purpural, vesicles, bullae, scales, pustules, nodules
      • other questions
        • does the rash itch or burn? how could this be a problem for a child?
        • what kind of treatment did the patient try?
        • what makes it better?
        • what makes it worse?
    • koplik's spot's - these are small red spots with white centers seen on the buccal mucosa near the level of the lower teeth and are only seen in measles prior to the appearance of the rash. what kind of care problems can you imagine the patient will have as a result of these oral lesions?
    • fever(intermittent) - what kind of problems related to fever will a child have?
    • difficulty in breathing - what kind of breathing problems will a child have?
    • vital signs
    to determine your nursing diagnoses you need to refer to a nursing diagnosis reference. the above data that you have are the symptoms that you will use in looking for nursing diagnoses that have defining characteristics that match with them. there are two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free if you do not have a nursing diagnosis reference:
  8. by   maely
    hi.. thank you for the reply. i just would like to ask if this is a correct nursing diadnosis:

    Tachypnea r/t fever as manifested by difficulty in breathing

    thanks again.
    Last edit by maely on Apr 12, '08
  9. by   PsychNurseWannaBe
    Quote from maely
    hi.. thank you for the reply. i just would like to ask if this is a correct nursing diadnosis:

    Tachypnea r/t fever as manifested by difficulty in breathing

    thanks again.
    Tachypnea is not a nursing diagnosis.

    Ineffective breathing pattern r/t (what do you think this is r/t?, hyperventilation, pain, etc.) AEB (what is the patient exhibiting... SOB, dyspnea, use of accessory muscles, etc.)
  10. by   maely
    IS Ineffective breathing pattern r/t Tachypnea correct?
  11. by   Daytonite
    is this a correct nursing diagnosis: tachypnea r/t fever as manifested by difficulty in breathing

    (1) tachypnea is a symptom
    (2) tachypnea is not a nanda approved nursing diagnosis
    (3) fever could not be an underlying cause of the tachypnea which is what the "r/t" part of the diagnostic part of the diagnostic statement represents; fever is also a symptom

    is ineffective breathing pattern r/t tachypnea correct?
    only if the tachypnea is so bad it is causing muscle fatigue. usually we think of tachypnea as a symptom. ineffective breathing is defined by nanda as inspiration or expiration that does not provide adequate ventilation (page 26, nanda-i nursing diagnoses: definitions & classification 2007-2008). nanda lists the causes for ineffective breathing as being:
    • anxiety
    • body position
    • bony deformity
    • chest wall deformity
    • cognitive impairment
    • fatigue
    • hyperventilation
    • hypoventilation syndrome
    • musculoskeletal impairment
    • neurological immaturity
    • neurological dysfunction
    • obesity
    • pain
    • perception impairment
    • respiratory muscle fatigue
    • spinal cord injury
    the proper way to construct a nursing diagnostic statement is by following this structural formula mnemonic:

    p - e - s
    p= problem
    e= etiology
    s = symptoms
    problem - etiology(ies) - symptoms

    these are, in nanda language

    nursing diagnosis - related factor(s) - defining characteristic(s)

    in a care plan they might look like this:

    problem [related to]etiology(ies)[as evidenced by]symptom(s)


    nursing diagnosis [related to] related factor(s) [as evidenced by] defining characteristic(s)

    the related factor is the underlying cause of the problem, or the cause, of the signs and symptoms that the patient is having. to help you determine a related factor it is often helpful to know the pathophysiology of the medical disease process going on in the patient. to help you in determining a related factor you can ask yourself "is this the cause of the problem (meaning the nursing diagnosis)", or "is this what is causing the symptoms". "by taking away this factor, will the symptoms go away?" remember this important rule: you cannot list any medical diagnosis as a related factor. you have to state a medical condition in some other scientific terms. as an example, we don't say a patient is "dehydrated" since that is a medical diagnosis, but we can say "fluid deficit". they essentially mean the same thing--the difference is in the phrasing of the words.

    the defining characteristics are always the signs and symptoms that you discovered during your assessment activities. these will be anything from the same signs and symptoms that doctors use to statements made by patients that indicate something wrong to adl evaluations that were not normal.
    Last edit by Daytonite on Apr 13, '08