Care plan HELP!!! PLEASE!!

step 1 assessment - collect as much data as you can about the patient's medical condition and treatment, its pathophysiology, signs and symptoms, possible complications; include your own physical assessment of the patient, and assessment of their ability to perform adl's; you are looking for all abnormal data

• periorbital cellulitis of right eye
  
• had a cold and headache for 4 days with a fever
  
• had a picc line inserted in the l ac for home care antibiotics
  

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - don't forget to include the symptoms of the periorbital cellulitis (i don't see any listed), any visual disturbances, signs and symptoms of the cold that may still be remaining (is she still coughing and have congested lungs? does she still have a headache?). since she is 15 years old she is still a child and that affects the way she views the world and how we deal with her, so her developmental stage is important to determine and incorporate into your assessment. look at erickson's developmental stages since she will most likely fit under either the adolescent stage (identity vs. role confusion) where the child is under role model and peer pressure to try many different roles (good patient?) to integrate them into their self-image of themselves. could that account for some of her anxiety?

• 15 year old female
  
• extremely anxious about the picc line
  
• sed rate 76 high -what does this mean?
  
• crp 2.0 high what does this mean?
  
• gluc 144 high - why is this elevated if she in not diabetic?
  
• alk phos 175 high - this level is usually elevated in 15 year olds because of the increased bone growth
  
• lymph, absolute 1.3 low - what does this mean?
  
• monocyte, % 18.9 high - what does this mean?
  

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - after you get more abnormal symptoms on your list, then begin looking for diagnoses to go with them.

anxiety r/t picc line insertion

• http://picclinenursing.com/picc_lines.html
  - this is a patient and nurse picc information website
  
  
• picc line instruction sheet.doc
  
  

risk for infection r/t picc line insertion. i didnt know if i could you risk for infection because she already has an infection.

• strategies to prevent the problem from happening in the first place
  
  
• monitoring for the specific signs and symptoms of sepsis
  
  
• reporting any symptoms that do occur to the doctor or other concerned professional
  
  

This infection must be significant if they feel she needs a PICC line for antibiotics. What is the infection and how is it affecting her vision?

just thinking about that i would be scared of going blind!

the diagnosis would be impaired tissue integrity r/t inflammation of eye secondary to staph infection. if there is any kind of wound care for the eye it can be included under that diagnosis. you can't say cellulitis because it's a medical diagnosis and it doesn't identify where the area is.

the double vision would have been an disturbed sensory perception, visual r/t swollen external eye tissues aeb blurred vision.

there's a lot of teaching connected with the care of the picc line. i know, i had one for 6 months and i was an iv therapist and thought i knew everything. i teetered on the brink of sepsis most of the 6 months i had the line but it could never be established.