Care plan assistance, please!

nurseprnRN, BSN, RN · Mar 23, 2012

i don't think this is a delayed-development thing; i'm not seeing anything in those risk factors that fit your description of this 16-year-old. (i am looking in the nanda-i 2012-2014, which is the definitive resource for nursing diagnoses. if you don't have it, get it at your fave online bookseller.)

instead, look under the nursing diagnoses for coping/stress tolerance. it sounds as if this kid is regressing a bit, which is completely understandable; this is a coping mechanism. i can see defining characteristics that fit this well, and they will help you develop your nursing plan of care in a more age-appropriate way.

WanderingRN2Be · Mar 23, 2012

Thanks GrnTea....this is looking a little bit better, but still, not all of these interventions seem appropriate, or at least, they are what I am imagining they should be. (scratches head) Im still swimming in my NANDA trying to find exactly what I am looking for....

WanderingRN2Be · Mar 23, 2012

Maybe I am better off going the...readiness for enhanced self care...route...bleh.

CT Pixie, BSN, RN · Mar 23, 2012

Could she be asking her mom for help because it hurts for her to do it herself and not so much to do with her 'regressing'? After having a surgery on my chest, if my mom was around to help me it would have been a blessing. Opening a bottle was literally impossible, brushing my teeth..was to say the least..interesting. And my surgery was nothing near what she had.

WanderingRN2Be · Mar 23, 2012

Hey Pixie, thats totally possible, but her pain was 3/10 when I woke her up for vitals this morning...and after getting a dose of dilaudid for the removal of her posterior chest tube (she still has an anterior tube) her pain was a 1/10...and this is after getting cleaned up and in a new gown, ambulating and eating. So, I guess I wasn't looking at the pain aspect as she rated it so low, even though she hadn't had pain meds since last night...until the dc of the post chest tube today. Normally, she won't take pain meds even when she is reporting 6/10. I think she took the dilaudid the MD offered her more because she was scared of the pain she might experience with the d/c of the post chest tube.

So, again, I wasnt factoring in pain when I decided on a diagnosis.

Esme12, ASN, BSN, RN · Mar 23, 2012

Think Erickson's growth and development. Erikson's Psychosocial Stages Summary Chart

[TABLE]

[TR]

[TD]Adolescence (12 to 18 years)[/TD]

[TD]Identity vs. Role Confusion[/TD]

[TD]Social Relationships[/TD]

[TD]Teens need to develop a sense of self and personal identity. Success leads to an ability to stay true to yourself, while failure leads to role confusion and a weak sense of self.[/TD]

[/TR]

[/TABLE]

Disturbed Body Image

NANDA-I Definition: Confusion in mental picture of one's physical self

Body image is the attitude a person has about the actual or perceived structure or function of all or parts of his or her body. This attitude is dynamic and is altered through interaction with other persons and situations, and it is influenced by age and developmental level. As an important part of one's self-concept, body image disturbance can have a profound impact on how individuals view their overall selves

Acknowledge normalcy of emotional response to actual or perceived change in body structure or function.Experiencing stages of grief over loss of a body part or function is normal and typically involves a period of denial, the length of which varies between individuals.

Help the patient identify actual changes.Patients may perceive changes that are not present or real, or they place an unrealistic value on a body structure or function.

Encourage verbalization of positive or negative feelings about the actual or perceived change.

It is worthwhile to encourage the patient to separate feelings about changes in body structure and/or function from feelings about self-worth. Expression of feelings can enhance the person's coping strategies.

Assist the patient in incorporating actual changes into ADLs, social life, interpersonal relationships, and occupational activities.

Opportunities for positive feedback and success in social situations may hasten adaptation.

Demonstrate positive caring in routine activities.

Situational Low Self-Esteem

NANDA-I Definition: Development of a negative perception of self-worth in response to current situation (specify)

Self-esteem is a component of an individual's self-concept. Positive self-esteem is based on the person's feeling worthwhile and capable of responding to challenges and stressors. Low self-esteem represents a mild to marked alteration in an individual's view of himself or herself, including negative self-evaluation or feelings about self or capabilities. This change in self-esteem is a temporary state in response to feeling unable to manage the current situation. One's self-esteem is affected by (and may also affect) ability to function in the larger world and relate to others within it. Self-esteem disturbance may be expressed directly or indirectly. Cultural norms, gender, and age are variables that influence how an individual perceives himself or herself. Powerlessness

NANDA-I Definition: Perception that one's own action will not significantly affect an outcome; a perceived lack of control over a current situation or immediate happening

Powerlessness may be expressed at any time during a patient's illness. During an acute episode, people used to being in control may temporarily find themselves unable to navigate the health care system and environment. The medical jargon, the swiftness with which decisions are expected to be made, and the vast array of health care providers to which the patient has to relate can all cause a feeling of powerlessness. This response is compounded by patients of cultural, religious, or ethnic backgrounds that differ from those of the dominant health care providers. Patients with chronic, debilitating, or terminal illnesses may have long-term feelings of powerlessness because they are unable to change their inevitable outcomes. Older patients are especially susceptible to the threat of loss of control and independence that comes with aging, as well as the consequences of illness and disease.

Encourage verbalization of feelings, perceptions, and fears about making decisions.This approach creates a supportive climate and sends a message of caring.

Consult the patient regarding his or her care (e.g., treatment options, convenience of visits, or time of activities of daily living).This approach by the nurse promotes self-control and ownership by respecting and encouraging patient involvement in decision making.

Acknowledge the patient's knowledge of self and personal situation.

A patient's perception of powerlessness can make a profound alteration in his or her thought processes.

Enhance the patient's sense of autonomy. Do this by involving the patient in decision making, by giving information, and by enabling the patient to control the environment as appropriate.

Patients become dependent in the "high-tech" medical environment and may relegate decision making to the health care providers. This may be especially evident in patients of cultures or ethnic heritages different from the dominant health care providers.

Encourage the patient to identify strengths.

Review of past coping experiences and prior decision-making skills may assist the patient in recognizing inner strengths. Self-confidence and security come with a sense of control.

Assist the patient in reexamining negative perceptions of the situation.

The patient may have misconceptions or unrealistic expectations for the situation.

Eliminate unpredictability of events by allowing adequate preparation for tests or procedures.

Information can provide a sense of control.

Gulanick: Nursing Care Plans, 7th Edition

This teenager has cancer and has a scar on her body. All children no matter how old they are want their mothers when they are scared and injured. They will emotionally regress to a younger stage.

CT Pixie, BSN, RN · Mar 23, 2012

Hey Pixie, thats totally possible, but her pain was 3/10 when I woke her up for vitals this morning...and after getting a dose of dilaudid for the removal of her posterior chest tube (she still has an anterior tube) her pain was a 1/10...and this is after getting cleaned up and in a new gown, ambulating and eating. So, I guess I wasn't looking at the pain aspect as she rated it so low, even though she hadn't had pain meds since last night...until the dc of the post chest tube today. Normally, she won't take pain meds even when she is reporting 6/10. I think she took the dilaudid the MD offered her more because she was scared of the pain she might experience with the d/c of the post chest tube.
So, again, I wasnt factoring in pain when I decided on a diagnosis.

Well, when I had my surgery, i had pain (like her while sitting doing nothing it was a 2-3/10 but when I moved, attempted to brush my teeth, it went up..but back down when I stopped and rested. This may be TMI, but even trying to get toilet paper and using it was a painful thing..) Being me (not wanting people to worry about me), I didn't let on how much the pain escelated when I moved, did things. She could be doing the same thing.

But like Esme said, this poor girl is 16. Just had major surgery, has a scar on her chest (think how she thinks it will look in a bathing suit), she got a dx of cancer..she was scared! And As Esme said, almost everyone wants their mom to help and care for them when they are sick and hurting. I'm going to be 43 in April and if sick enough..and when my mom offers, I will still allow my mom to come over and 'fix' her baby girl.

WanderingRN2Be · Mar 23, 2012

Esme, I think you are right on when you say they will have issues that lead to regression. I think the point I am trying to make is that with recurrence (or the possibility of) I am wanting to do teaching that will lead to the patient gaining and maintaining as much normalcy and independence as possible....but the interventions are where I am stumped. I think the way to go may be switching up the DX.

Thanks for your input!

Pixie....I know when I am sick, I want someone to help take care of me...but at 16, no matter what my issue...I would NOT have wanted my mom to bathe me. Just seems like a pretty severe regression, although, situationally its understandable, and this girl is not me.

Thanks for your insight and suggestions!

Esme12, ASN, BSN, RN · Mar 24, 2012

That would be powerlessness.....

Powerlessness

NANDA-I Definition:

Perception that one's own action will not significantly affect an outcome; a perceived lack of control over a current situation or immediate happening....cancer

Powerlessness may be expressed at any time during a patient's illness. During an acute episode, people used to being in control may temporarily find themselves unable to navigate the health care system and environment. The medical jargon, the swiftness with which decisions are expected to be made, and the vast array of health care providers to which the patient has to relate can all cause a feeling of powerlessness.

This response is compounded by patients of cultural, religious, or ethnic backgrounds that differ from those of the dominant health care providers. Patients with chronic, debilitating, or terminal illnesses may have long-term feelings of powerlessness because they are unable to change their inevitable outcomes.

Encourage verbalization of feelings, perceptions, and fears about making decisions. This approach creates a supportive climate and sends a message of caring.

Consult the patient regarding his or her care (e.g., treatment options, convenience of visits, or time of activities of daily living). This approach by the nurse promotes self-control and ownership by respecting and encouraging patient involvement in decision making.

Acknowledge the patient's knowledge of self and personal situation.

A patient's perception of powerlessness can make a profound alteration in his or her thought processes.

Enhance the patient's sense of autonomy. Do this by involving the patient in decision making, by giving information, and by enabling the patient to control the environment as appropriate.

Encourage the patient to identify strengths.

Review of past coping experiences and prior decision-making skills may assist the patient in recognizing inner strengths. Self-confidence and security come with a sense of control.

The patient may have misconceptions or unrealistic expectations for the situation.

Eliminate unpredictability of events by allowing adequate preparation for tests or procedures.

Assist the patient in reexamining negative perceptions of the situation.

Information can provide a sense of control.

Gulanick: Nursing Care Plans, 7th Edition

nurseprnRN, BSN, RN · Mar 25, 2012

op, say a big thank you to esme (and hit that "like" button) for giving you all these answers!

(you can tell that i don't do that too often.... but i did tell you where to look about the regression/coping thang:d.)

gatoraims RN · Mar 27, 2012

Esme was a GREAT help! I am just now entering my the LPN-RN transition program. I am glad that if I need a shoulder to lean on there is Esme as well as other great nurses here to help.