Brain fart or actually an idiot?

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:banghead:OK, for whatever reason I am unable to think tonight. I have to do a care plan on my 26 day old infant that came in with dehydration. No diarrhea, no vomiting, does have a fever... Labs are fairly stable with exception of mild elevation of potassium at 5.5 which is expected. My plan has to have 3 nursing dx and i can only muster up one: Fluid volume deficit (r/t insensible losses, fever...) Lungs are clear, wbcs are fine, breast fed, still has adequate output, on IV fluids now... I suppose potential for infection could be one but based on what (besides the fever?) I figure I just completely fell off the wagon tonight. There is also an issue of "breast fed jaundice" with a total bili of 6.2 (not too crazy high...) Any suggestions? Thanks a bazillion

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Well, what's a fever called in nursing diagnosese? How about hypothermia?

Infants are ALWAYS risk for injury r/t maturational age.

Nursing diagnoses are hard simply because they make you take straight language and convolute it. You have a dehydrated infant with a fever. Now you have to put it into a complicated language.

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Hypothermia is too cool... but I get your point. Thanks.

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Specializes in ED, ICU, PACU.

When having one of those brain farts (no, you are not an idiot), you can always dig deep for the old standby that covers any situation: Knowledge deficit. Of course the infant certainly has one; but, parent of a newborn always needs education, especially when their child is ill.

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:banghead:OK, for whatever reason I am unable to think tonight. I have to do a care plan on my 26 day old infant that came in with dehydration. No diarrhea, no vomiting, does have a fever... Labs are fairly stable with exception of mild elevation of potassium at 5.5 which is expected. My plan has to have 3 nursing dx and i can only muster up one: Fluid volume deficit (r/t insensible losses, fever...) Lungs are clear, wbcs are fine, breast fed, still has adequate output, on IV fluids now... I suppose potential for infection could be one but based on what (besides the fever?) I figure I just completely fell off the wagon tonight. There is also an issue of "breast fed jaundice" with a total bili of 6.2 (not too crazy high...) Any suggestions? Thanks a bazillion

insufficient fluid volume r/t increased vulnerability secondary to decreased fluid reserve

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Risk for infection works..for at least three reasons I can think of off hand

1) insertion site of the IV

2) assessing the IV with syringe for blood draws

3) being in the hospital in and of itself is a risk for infection

You could also go with Tissue Integrity, impaired as another dx..the IV site has created an opening in skin that was otherwise intact.

So with your Fluid volume deficit and risk for infection, Sue's suggestion of Hyperthermia, and mine of Impaired skin integrity there are four to play around with.

What about a psycho-social one, the baby is at the Trust vs Mistrust in Ericksons stage of development. Maybe you could use one of the psych ones.

what about Breastfeeding, interrupted

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hyperthermia r/t insufficient hydration secondary to dehydration

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-risk for infection r/t vulnerability of infant, lack of normal flora, open wound

-risk for impaired skin integrity r/t susceptibility to nosicomial infection (lack of normal flora)

-ineffective thermoregulation

-risk for ineffective therapeutic regimen related to insuffiecient knowledge

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Specializes in med/surg, telemetry, IV therapy, mgmt.

think about what you know about the assessment findings of a normal newborn compared to an adult. what's different? for one thing newborns can't regulate their body temperature which is why we don't leave them exposed to the room atmosphere for very long with just a diaper covering them. that's ineffective thermoregulation r/t immature compensation for changes in environmental temperature. if the baby has a fever use hyperthermia ([color=#3366ff]hyperthermia). some newborns just have a few difficulties with excessive secretions in the respiratory track (the big hint here is that the nurses will keep a bulb syringe nearby the baby) so ineffective airway clearance ([color=#3366ff]ineffective airway clearance) can be used. they also have a stump from the umbilical cord hanging off their future belly button. do you? are they treating this cord stump? if it's inflamed or there are umbilical cord problems there is risk for infection, so you can use risk for infection r/t break in skin integrity at umbilical cord site ([color=#3366ff]risk for infection). if the baby has been circumcised that is another reason for a risk of infection. if this baby is breastfeeding and having no problems use effective breastfeeding. some babies just don't start feeding well at first by breast or bottle--it happens. these kids are imbalanced nutrition: less than body requirements r/t poor infant feeding behaviors ([color=#3366ff]imbalanced nutrition: less than body requirements). if the baby is under the bililight for hyperbilirubinemia the nursing diagnosis to use is risk for injury r/t phototherapy ([color=#3366ff]risk for injury).

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Hypothermia is too cool... but I get your point. Thanks.

Oh, groan - *I* had a brain fart. HyPERthermia.

;)

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