Nursing Care Plan 10y Boy w/ Tonsillitis

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Hi everyone I'm new to nursing care plans, as in just started to learn them a week ago and I have a case study on a 10y boy with Tonsillitis. Wheezes noted in RLL and LLL, Respiration's are even and unlabored. chest rise is symmetrical. O2 sat 98 pain 5, t-101.3. Pulse 99. Skin and Oral Mucous dryness noted. Tonsils swollen +3/+3. Patient has no coping skills due to no hard times in his life. Doesn't want friends to know about his asthma issue. Ok so heres my priority nursing diagnosis-

Ineffective airway clearance r/t obstruction of inflamed tissue

Patient outcome/goal: Patient will maintain patent airways during hospitalization as evidenced by lung sounds are clear to auscultation bilaterally by discharge.

Then I also need a psychosocial issue, so I picked Ineffective Coping r/t new illness

Patient Outcome/goal is what Im stuck on! Would this be an ineffective coping issue because he didn't have any coping skills in the first place? or Would this be an anxiety issue?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Here is what I know.......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.

What is your assessment? What are the vital signs? What is your assessment. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future.

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.

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. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

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

  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.

SO based on this patient what would be your first concern?

I have a case study on a 10y boy with Tonsillitis. Wheezes noted in RLL and LLL, Respiration's are even and unlabored..... chest rise is symmetrical. O2 sat 98 pain 5, t-101.3. Pulse 99. Skin and Oral Mucous dryness noted. Tonsils swollen +3/+3. Patient has no coping skills due to no hard times in his life. Doesn't want friends to know about his asthma issue.

So after you know what Tonsilitis is......Looking at your data.....what should be your first priority......what can hurt him the fastest? Remember that dehydration can be fatal.

While ineffective airway clearance is a risk for him during this illness what do you need to address now....which does he have "symptoms of"....with very swollen tonsils, throat pain and a fever.....dry skin and dry mucous membranes what is your first concern.

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Thanks For your reply, I really appreciate it. I was thinking more in terms of Maslows when I formed my priority diagnosis, and I guess since his RR is fine and breathing is fine I would go to the next thing correct? which would be the dry mucous membranes/potential dehydration?

Does this look right?

Patient will maintain adequate fluid volume and as evidenced by vital signs within normal limits and moist mucous membranes by discharge.

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The patient will demonstrate adequate fluid volume intake of 2400ml/day as evidenced by moist mucous membranes by discharge.

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If it's tonsils that might be an airway problem, lung sounds won't tell you anything. The lungs could be perfectly clear. What's the term for airway obstruction in the upper airway, or the sounds it makes? ::plays the jingle for 30 seconds while you look that up::

Adequate fluid volume intake is evidenced by more than just having a moist mouth. How about urine output appropriate for age/clear light in color, other VS that indicate fluid balance (specify)?

Good spot on the coping thing. You might want to check your NANDA-I 2012-2014 about resilience and roles, too.

(You haven't heard my NANDA-I commercial yet? Every student should have one whether or not the faculty remembered to put it on the bookstore list. This is THE resource on nursing diagnoses, because it has the only list approved by the international group approving them. About 1" thick in paperback, get it for free 2-day shipping for students from Amazon, and never get hassled by your faculty about nursing process and plans of care again. :) )

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Esme and GrnTea rock!! Emse and GrnTea rock!!

okay, okay, i admit, THIS is the most useless post. I just really liked their posts. Good stuff.

edit, oh my, that lil character is supposed to be doing a happy dance..whoops, he's not moving around. oh well.

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:thankya: We do appreciate the kind words! Tell our boss! :thankya:

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