hi, nygiants, and welcome to allnurses!
i usually am only on allnurses in the early morning hours and the early afternoon, plus i live on the west coast so i wouldn't have seen your post until now and it may be too late since you are probably getting ready to leave for your clinicals about now.
allnurses has two sticky threads with information on how to construct care plans
that you should check out because there is lots of helpful information scattered among the posts:
all care plans are based upon the assessment information that you obtain. this information generally comes from a thorough review of the patient's medical record, your interview of the patient and your physical examination of the patient. in this case you won't have all the information. you will have to base what you have to work with on with the patient's medical diagnoses alone and what little you have to go on about the patient. this is not the ideal situation, but the final care plan you turn in will be based on much different criteria. your instructors are trying to get you to think about how the nursing process works.
you can't start thinking about any nursing diagnoses until you look at the symptoms your patient has and the problems they might be causing. a doctor wouldn't look at you and say "hmm, maybe you have this or that," without considering your symptoms. would you go to a doctor who did that? we nurses don't perform the process diagnose any differently! you must understand, if you don't already, that nursing process, and the care plan which is the documentation of the nursing process, is nothing more than a problem solving method. that's all. a nursing diagnosis is nothing more than a label
that we put on a problem that the patient has. nanda (north american nursing diagnosis association) has very nicely over the years helped us out by giving us all the wording we need to state these problems. we used to sit around and have to think up the wording to use back in the early 70s when i came out of nursing school. now, all you need is a copy of the nanda taxonomy, look up the wording, and you're good to go!
i went through the information you posted and this is the important stuff:
- medical diagnoses:
- pneumonia (is this the admitting diagnosis?)
- ischemic encephalopathy at birth
- history of mrsa
- history of nissan fundoplication (this is a surgery to correct gerd and acid reflux)
- data gathered from the limited assessment:
- 15-years old
- has a g-tube
- on contact precautions
- on seizure precautions
- underweight--40 kg
- under height--143cm
first of all, i would tell you to get a reference book and look up the symptoms of pneumonia. these would be the symptoms you would expect to find in someone who has plain old pneumonia--not community acquired pneumonia, lobular pneumonia, viral pneumonia--just plain old pneumonia of the bacterial sort. those symptoms are:
- sputum production
- dullness over the affected area
- crackles, wheezing, or rhonchi
- decreased breath sounds
- decreased fremitus
- use of accessory muscles to breath
- (page 614, nurse's 5-minute clinical consult: diseases from lippincott williams & wilkins)
and, that is what you begin to choose your potential nursing diagnoses from. every nursing diagnosis has a list of signs and symptoms (nanda calls them defining characteristics). you have to understand the underlying pathophysiology of the patient's disease process in order to nail the correct related factor that is causing the problem (nursing diagnosis) that leads to the symptoms in order to get your nursing diagnostic statement worded correctly. the nanda taxonomy helps you with this. just about every care plan book and nursing diagnosis reference book on the market today includes the nanda taxonomy in it. most people skip over it and go right to the nursing interventions. you need to start look at the defining characteristics that are listed with the nursing diagnoses because these are the symptoms that define that diagnosis.
now, from those symptoms of pneumonia i can easily extrapolate two nursing diagnoses, listed in priority order (by maslow's hierarchy of needs). i'm including links to online webpages that have not only the nanda taxonomy information, but also goals and nursing interventions.
ineffective airway clearance
r/t excessive mucus, retained secretions, and infection aeb crackles, wheezes and rhonchi in the lungs, diminished breath sounds, excessive sputum production. [color=#3366ff]ineffective airway clearance
r/t infection of lungs aeb increase in body temperature above normal range, tachypnea and seizures. [with this child's history he is a seizure waiting to happen with an elevated temperature]. [color=#3366ff]hyperthermia
now, when you're ready to write the final care plan and if you need help with it, ask. i see a number of other nursing diagnoses that would apply here, but gave you the two most important ones that would stand out in my mind based on the information you gave. this patient has developmental and nutritional problems. and, based on what you find in your physical assessment may have a gas exchange problem as well.