Hey all...last week had a 3y11mo old M on the floor during one of my pediatrics clinicals. I took him with a fellow student..his primary medical diagnoses were otitis media and strep throat...I am fresh into pediatrics, so i am inexperienced with communicating directly w/ the patient (this is my oldest pt. so far)..I mostly communicated w/ this particular pt. through mom..I guess he is a bit developmentally delayed and wasn't a talker. I'm sitting here trying to find a 2nd physical diagnosis. Vitals were great, no fever, MAR only said rocephin and prn Motrin...little guy just laid in bed all day with mom watching cartoons and wasn't exactly happy to see us when we came for our assessment and subsequent q4 vitals (thus the irritability in the dx below)
My 1st is pain r/t ear infection and strep throat aeb guarding behavior, irritability, and moaning
I've thought about disturbed sleep pattern r/t being in the hospital, but i honestly don't know how the little fella sleeps at home so I can't "prove" that he has a disturbed sleep pattern..the book I'm using is the Gulanick/Myers "Nursing Care Plans" ed.6 -- absolutely wonderful for adult 1/med-surg, but i am finding virtually no help with pediatrics! I was going to use something having to do with his diet because he didn't eat well during my shift, but his appearance was unremarkable...37lb, otherwise healthy 3y.o.
My psychosocial dx is going to be impaired verbal communication r/t developmental delay aeb malformed words and sentences and difficulty in understanding patient's speech
..just popped this off the top of my head, will probably get some fine tuning..suggestions welcome!
I'm not trying to get anyone to do my homework here...just need some thinking that's outside of the box i'm trapped in!