Care plan HELP!!! PLEASE!!

Daytonite, BSN, RN · Feb 23, 2009

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

anxiety is a very broad term and requires explanation. did you talk with her? what kind of things was she telling you that led you to make a judgment that she was anxious? i would look at her level of development and where she needs to be as a 15-year old first. her anxiety may be a symptom of that rather than a problem in and of itself. if she is in the normal adolescent stage of identity vs. role confusion part of her anxiety (no symptoms of which you listed) would be connected with how she is expected to perform her role as a patient in caring for this picc line. that's a big responsibility for a 15-year old. (i've had a picc line for 6 months and i know what home care is involved with it.) rather than anxiety as being the major problem here i would suspect that

ineffective role performance

(related factors for this diagnosis that fit with this patient might include body image alteration, low self-esteem, developmental level, school demands, young age, and/or lack of knowledge) is more likely and in keeping with her developmental level. as a teenager there may also be some

disturbed body image

going on (related factors for this diagnosis that fit with this patient might include perceptions of disfigurement, fear of rejection by others, being seen by peers as being different from everyone else), but i don't know since there wasn't any data posted in regard to this. there may also just be

deficient knowledge, picc care r/t lack of knowledge

that is needed.

when the diagnosis of

anxiety

is used its related factor must be a threat, change or crisis that causes an anticipation of danger. since the picc line has already been done "

picc line insertion

" as the related factor doesn't make sense. it would if the insertion was going to happen in the next few days, but it has already occurred. so, what is she afraid of now? that makes me think that there are other things she is worried about: the care of the picc line, how the picc line will look to others--and there are other diagnoses as i mentioned just above for those.

see:

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.

it is appropriate to use this. the infection being avoided is sepsis which, at this point, she does not have. strict aseptic technique is used for all dressing changes of the picc line to avoid introducing bacteria into the wound. the tip of the picc line is in the vena cava of the heart. the last place you want bacteria to migrate is along this picc line to the vena cava where they can be dropped directly into the bloodstream and carried to any organ.

sepsis:

the spread of an infection from its initial site to the bloodstream initiating a response that adversely affects blood flow to vital organs.

interventions for this nursing diagnosis is limited to:

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

Deannalynn · Feb 23, 2009

Thank you so much, i have all my labs written down with what they mean, i just thought it would be too much to post, so i didnt. The pt has significant anxiety about the PICC line insertion, she was crying and talking about it non stop, she did NOT want it done. So that is why i was using anxiety. They had a Child life specialist come in a talk to her about it, they used music therapy and distraction.

The problem is i need ONE more nursing dx, and i cant think of one that wouldnt be psychosocial. Do you have any ideas?

Daytonite, BSN, RN · Feb 23, 2009

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?

Deannalynn · Feb 23, 2009

I believe it was a staph infection, but dont quote me on that. :) It did effect her vision because her eye swelled up so much. After they drained it, she had blurred vision and was seeing double. By discharge her vision was back to normal. I was thinking i could do impaired tissue integrity r/t cellulitis

Daytonite, BSN, RN · Feb 23, 2009

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.

Deannalynn · Feb 23, 2009

wow that is crazy how even you were teatering on the sepsis line. I really appreciate you help, you are great at this!