Nursing Diagnosis help for 7 year old pt

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    Hi all,

    I'm having a difficult time with my careplan for my little guy. He came in for constipation x3weeks with no relief after trying miralax and enemas. MD decided to drop an NG and do a continuous infusion of GoLytely at 300ml/hr. Pt is on a clr diet with no red foods or fluids allowed (so as to not mistake it for blood).

    I was reading my NANDA book and Diarrhea is a nursing diagnoses, but it seems too general. Other considerations were impaired skin integrity, impaired (or risk for) imbalanced electrolytes or acid/base, and fluid volume deficit.

    I can't seem to prioritize what's the most important. Any thoughts? Initially I thought fluid volume was important, but he is getting PO fluids and the MD was okay with this, as the IV start was a big ordeal (we're talking IM sedatives) and since it went bad, he'd like to steer clear of another. During my shift, he had 3 clear yellow stools, which is the goal for obtaining the KUB x-ray to confirm he's empty. Well mom says his stools have been that way the whole time so we're not sure if they want them even more clear (there was very little mucous-like sediment as it was) or what. Anyway, X-ray said there's still some stool left in there, so we can't figure out why it isn't coming out, which could be another potential problem. Gahhh!!!!

    Sorry this post is kind of all over the place. Let me know if I missed anything, and thanks for your help!

    Jeremy
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    Random thoughts: I think "Dysfunctional gastrointestinal motility" would be an appropriate nursing Dx b/c it covers constipation,diarrhea,& the wierd status quo you are describing. Outcomes:Passage of formed stool, relief of constipation without complications, & patient/caregiver understanding of steps to prevent constipation in the future. You'd be monitoring for effectiveness of Tx and SE, and you would counsel patient/caregiver on prevention.
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    That's the same thing as "Altered Elimination", right? That was my other thought but, again, I thought it seemed too general. You're right though- the kid has too much going on to only address with 3 NANDA's.

    Thanks for the response! I'll work with that.

    Jeremy
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    Quote from EMTJeremy
    I was reading my NANDA book and Diarrhea is a nursing diagnoses, but it seems too general. Other considerations were impaired skin integrity, impaired (or risk for) imbalanced electrolytes or acid/base, and fluid volume deficit.
    Be careful not to get caught up trying to find nursing diagnoses for the medical diagnosis. Instead, look at your whole patient. Does he have signs of impaired skin integrity? What makes you think he would have a fluid volume deficit? What are his labs? What is your assessment data?

    Don't forget the psycho-social aspect, which is a huge concern in hospitalized kids. You mentioned he needed sedatives just to start a PIV. Then he needed an NG tube, x-rays, enemas, and he can't eat his favorite foods. He's in an unfamiliar place, surrounded by strangers and mom and dad may not be with him all the time. What diagnoses can you come up with that address this situation?

    ETA: Lots of nursing diagnoses are general. Otherwise there would be thousands of NANDA diagnoses. You make the diagnosis specific you your patient by listing the related factors and evidence. You can even specify Altered Elimination, Constipation.
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    There are all sorts of medical and psych diagnoses that could account for hypomobility or stool retention. Perhaps researching those will give you some ideas about how this child and these parents are dealing with this problem, and help you to identify nursing diagnoses that apply based on your assessment of the effects of those medical dx. Remember, your nursing diagnoses are not based on medical ones, but your own nursing assessment. You might be observing results of medical diagnosis, but you might be seeing something entirely different. Think about that.
  8. 0
    Quote from EMTJeremy
    Hi all,

    I'm having a difficult time with my careplan for my little guy. He came in for constipation x3weeks with no relief after trying miralax and enemas. MD decided to drop an NG and do a continuous infusion of GoLytely at 300ml/hr. Pt is on a clr diet with no red foods or fluids allowed (so as to not mistake it for blood).

    I was reading my NANDA book and Diarrhea is a nursing diagnoses, but it seems too general. Other considerations were impaired skin integrity, impaired (or risk for) imbalanced electrolytes or acid/base, and fluid volume deficit.

    I can't seem to prioritize what's the most important. Any thoughts? Initially I thought fluid volume was important, but he is getting PO fluids and the MD was okay with this, as the IV start was a big ordeal (we're talking IM sedatives) and since it went bad, he'd like to steer clear of another. During my shift, he had 3 clear yellow stools, which is the goal for obtaining the KUB x-ray to confirm he's empty. Well mom says his stools have been that way the whole time so we're not sure if they want them even more clear (there was very little mucous-like sediment as it was) or what. Anyway, X-ray said there's still some stool left in there, so we can't figure out why it isn't coming out, which could be another potential problem. Gahhh!!!!

    Sorry this post is kind of all over the place. Let me know if I missed anything, and thanks for your help!

    Jeremy
    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 patient saying?. 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. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT... what care plan book do you use.

    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. From what you posted I do not have the information necessary to make a nursing diagnosis.

    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.

    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 tell me about your patient
    .......What do they need? What do they c/o? What is your assessment......What does this tell me about the patient? did they have pain? Do they have a history of this? Have they always been a stool hoarder? There is not enough information about the patient to develop a good ND.


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