Care Plan Help

[Peachez8207]

Seriously you would think I would be better at these by now. I think my brain is fried from school this is my last quarter and last 2 care plans.

I have 5 finals to study for and I can't think anymore.

Here is a little info about my patient.

AAM 4 hours old, decreased muscle tone, expiratory grunting accompanied by nasal flaring. Weak cry, his top lip extends over his bottom lip, there was some concern over his palate being intact on inspection it is intact. During pediatric examination a sacral dimple was found an spinal ultrasound was ordered but I have no idea the results because this was my last day of clinicals.

I want to use Impaired skin integrity R/t genetic defect AEB indentation of the skin above buttocks.

Risk for infection r/t this is where I get stuck because I can't use the same r/t as the first diagnosis.

I can not for the life of me figure out a third Nursing Diagnosis I wated to use Risk for Impaired body image or Knowledge deficit but not sure how they apply to an infant.

If anyone can help me it would be greatly appreciated.

Signed in Advance burnt out nursing student.

:banghead::banghead::banghead::banghead::banghead::banghead::banghead::banghead::banghead::banghead:

[Daytonite, BSN, RN]

is he breastfeeding? effective breastfeeding r/t normal infant oral structure aeb eagerness to nurse and contentment after feeding. if there are breastfeeding problems, use ineffective breastfeeding.

no newborn can 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.

impaired skin integrity r/t genetic defect aeb indentation of the skin above buttocks. - good call

they also have a stump from the umbilical cord hanging off their future belly button. if it becomes inflamed or there are umbilical cord problems there is risk for infection, so you can use risk for infection r/t potential for break in skin integrity at umbilical cord site.

[suzi-Q]

Start with Maslow's and prioritize. This baby is having trouble breathing so I would start with that. Why is the baby having trouble? This will answer your related to for that. For the impaired skin integrity I would say r/t low muscle tone, but what you have is ok. Because of the lip issue does the baby have trouble feeding/sucking? That could lead you to a "risk for" diagnosis, but again probably related to the low muscle tone.

Hope this helps lead you in the right direction. It's the best I can do without more info. Hopefully you have more to work with than this little bit!? (Is this baby pre-mature, what are the abg's? etc. etc.)

Remember...prioritize first, then diagnose, then r/t.

[suzi-Q]

Oh well, ok, daytonite and I must have been typing at the same time. Can you tell I have alot less experience than she? Funny thing is I learned from her and she's the best so you got lucky that she saw your post!

[Peachez8207]

Thanks everyone. These nursing diagnosis really help I guess I was stuck because I was trying to relate all my nursing diagnosis to the sacral dimple.

[suzi-Q]

We have all been there. Near the end you are just tired and brain dead. Best wishes.

[Daytonite, BSN, RN]

Thanks everyone. These nursing diagnosis really help I guess I was stuck because I was trying to relate all my nursing diagnosis to the sacral dimple.

You have to remember to assess the total child. The sacral dimple stood out from the other stuff and probably shut off the rest of your thinking process. You can also back into abnormal assessment items by looking at what is being done for babies and asking yourself "why are they doing that?" especially when you don't see them doing those same things on adult patients.