Care Plan Help: Rotovirus/Diarrhea

[discobunni]

I am doing an assignment for a virtual patient and am having trouble connecting the dots to come up with the correct DX. We are suppose to include the top 2 priority DX and my instructions say DO NOT use Risk for or knowledge deficit for your DX. Please help...am I thinking along the right lines here...or what am I not considering that I should be??

Please pick apart my analysis...criticism welcome!!!

My patient is a 7 mo. old that presents with the following:

Subj. Data:

Mucousy Diarrhea x 4 days

oliguria

Obj. Data:

101.8F

P. 136

R. 38

BP 90/54

Abnormal labs as follows:

CO2 19 low

WBC 10.5 High

K+ 3.2 low

BUN 29 High

BM positive for rotovirus, slightly acidic

UA Spec. Gravity 1.028 high

Mother appears anxious and frightened. Pt. is anxious and frightened.

slight reduction in skin turgor.

Appears pale, lethargic, hyperactive bowel sounds, abdomen soft.

Doctor has diagnosed as moderately dehydrated.

I'm pretty sure about this one:

Deficient fluid volume r/t active fluid volume loss aeb BUN 29, slight reduction in skin turgor, UA Spec. Gravity 1.028

BUT...then what about the DX of Diarrhea r/t viral infection aeb (loose stool? Sounds rather redundant but what else would you use as evidence? LOL)

My biggest concern is about his RR of 38 and CO2 of 19.

Am I correct or not? The CO2 is only 1 point below normal. Does this qualify for Impaired Gas Exchange, if not when does it?? Then, what would I use as the r/t....the viral infection? How can I justify that? I don't understand the medical explanation behind that. My instructor likes the explanation of the disease process rather than the disease itself as the r/t.

So would I say viral invasion or something to that effect....ugh my brain is going bonkers.

OK, then there is

Altered Body Temperature r/t viral invasion (??) aeb t. 101.8F

and when does this become priority over fluid volume deficit?

Last but not least there is the NANDA DX of Anxiety, but that won't be priority over these.

There is also concern about the K+ but is this because the infection is having an effect on the heart....and the other factors need to be addressed to bring this back into balance? In a case like this, would the Dr. temporarily usually prescribe a K+ supplement in addition...or not (isn't a bad side effect of K+ diarrhea)??

Ohhhh, these care plans make my Brain hurt!!!!!!!! Can someone PLEASE help me organize my thoughts? Thanks!!!!!

Angela

[Daytonite, BSN, RN]

when you are given a "virtual patient", one of the first things you need to do is look up the signs and symptoms of any medical conditions you have been given. in this case, you have been told that the patient has a moderate degree of dehydration and a rotavirus in the gi track. you also know that infants are at a high risk for dehydration when they have fevers or diarrhea because they have a higher proportion of water to body weight. the hypokalemia could also be partly contributing to the diarrhea. the tachycardia, oliguria, slight reduction in skin turgor and labs are all symptoms of the dehydration.

signs and symptoms of rotavirus gastroenteritis are fever, nausea and vomiting followed by diarrhea which can result in dehydration. the virus lasts from 3 to 9 days.

so, you are correct in choosing deficient fluid volume r/t active fluid volume loss, however, there are more aeb items than you have included in your listing. deficient fluid volume r/t active fluid volume loss aeb tachycardia, oliguria, lethargy, elevated temperature, slight reduction in skin turgor, co2 of 19, potassium of 3.2, bun of 29, and specific gravity of urine of 1.028.

the diarrhea is due to the rotavirus which is causing either secretory or motility diarrhea. all you know is that the child has hyperactive bowel sounds which is a symptom of both types of diarrhea. secretory diarrhea, however, is usually caused by a bacteria or virus. you have written diarrhea r/t viral infection aeb (loose stool?). how about this. . .diarrhea r/t infectious process (secondary to rotavirus) aeb hyperactive bowel sounds and mucusy diarrhea x 4 days. it would be nice if the mother were able to say how many times a day the child was having the diarrhea stools. then, you would simply say "mucusy diarrhea stools 7 times per day".

the elevated respiratory rate is a symptom of the fever. so, is the tachycardia. the nursing diagnosis for this would be: hyperthermia r/t dehydration and infectious process aeb temperature of 101.8f, increased respiratory rate of 38, tachycardia of 136 and wbc count of 10.5.

i, personally, would not address anxiety in a 7 month old. i think it is related more to restlessness which is more of a physical symptom of pain. it probably is not a far piece of thinking here that the baby is having abdominal cramps from this virus and the resulting diarrhea and just can't express that to you. but since there are no other symptoms of pain, i wouldn't address it. also, you can't address the problems with the mother since she's not the patient unless her anxiety is affecting the care that will need to be given to the patient.

that addresses all the symptoms you listed except for the b/p which i think can be ignored.

as for prioritizing the diagnoses, i use maslow's hierarchy of needs as a guide. and, i have already addressed them in the order of priority that they belong.

1. deficient fluid volume (physiologic need for food and fluid)
   
2. diarrhea (physiologic need for elimination of wastes)
   
3. hyperthermia (physiologic need for control of temperature)

maslow prioritizes the physiological needs in the following order:

1. oxygen
   
2. food
   
3. elimination
   
4. temperature control
   
5. sex
   
6. movement
   
7. rest
   
8. comfort

[discobunni]

Thank you Daytonite you are the BBBEESSSSTT! You make it so much more understandable!

[Daytonite, BSN, RN]

what i did (and you might want to do this as well in the future) was cut and paste your original post to a word document. i then removed everything except what was an abnormal assessment (or symptom) that the patient had. this gave me a list of symptoms to work with. i recognized the defining characteristics for deficient fluid volume, diarrhea and hyperthermia right off the bat and started moving them around physically on the document so they were close to each other. i still went to my resource book to double check. i also did a little research on the symptoms for the rotavirus to make sure there wasn't any main symptom that wasn't listed since this was a non-existent patient. it's all about knowing and recognizing what is abnormal as opposed to normal during the assessment gathering. keep in mind that saying about "garbage in, garbage out". if you don't start with good and thorough assessment information in the first place, then you're not going to end up with much of anything to put into a care plan. that's why you'll see posts where people are stumped as to where to start with a care plan. they know there is a lot that needs to be done with the patient, but they can't figure out how to get to it via the written care plan process. it all starts with step #1, the assessment. that is the foundation. if things are left out of the assessment information, there is not much support for the rest of care plan. does that make sense?

[Ayrhia]

I know this is from 3 years ago, but I wanted to comment. Young children have high respiratory rates and high heart rates. So this evidence would not necessarily show that the child is experiencing tachycardia or tachypnea. As the child ages, these values will go down, to 60-100 bpm's and 16-20 RR. Their b/p will rise, so it is abnormal to see a child with a b/p of 120/80 as you would see in an adult.