hi everyone! i am in my 3rd semester of my program and am doing my pediatric rotation. i have to write 2 priority nursing diagnoses for my patient and i am having a tough time with my second diagnosis.
here is a little background:
my patient is 13 months old, has been in the hospital for 5 weeks, admitted for respiratory distress. patient has a tracheostomy and a feeding tube as well. this patient has agenesis of the corpus callosum (acc) which by definition is: an abnormality of brain structure, present at birth, that is characterized by partial or complete absence of the corpus callosum. the corpus callosum is a bundle of nerve fibers that connects the two hemispheres (halves) of the brain and allows information to pass back and forth between both sides.
patients meds are: acetic acid to clean trach site, budesonide inhalation suspension for prevention of asthma, lactobacillus rhamnosus-probiotic to stop growth of harmful bacteria in intestines, prevacid for acid reflux/heartburn, multivitamin with iron, oxycarbazpeine (anticonvulsant), vitamin k, and ursodiol.
patients abnormal labs are:
chloride 114 (norm 98-106)
bun 20 (norm 5-15)
cr 0.8 (norm 0.3-.06)
bili 1.1 (norm 0.2-0.9)
alb 2.6 (norm 3.8-5.1)
height: 25.98in
weight: 8.08kg (17.8lbs)
at 13 months the patients growth and development should be: walking with increasing confidence, climbs stairs, etc., turns book pages, drinks from a cup by holding it with two hands, explores objects by banging, shaking, throwing, dropping, should be responding to simple verbal requests such as "no", tries to imitate words, etc.
my patient however, layed in bed the majority of the day and showed no signs of any of the above. patient was not walking, no speech, but could follow sounds with his eyes and could squeeze my hands, and sleeps majority of day.
assessment data:
rr: 22
wob: labored (intermittently)
o2 stats: 100% on 3 l/min, 24% concentration
crackles in lung sounds, all lobes
temp: 35.9 celsius
absent cough
apical pulse: 138 regular rhythm
flacc score of 1 (given a 1 for activity; squirming, shifting back and forth, tense [restlessness])
suctioned 4x during shift, 1 deep suction
humidified air
patient gets tube feedings 45 ml/hr for 17 hours (peptamen junior)
soooo.... i know that's a lot of info. here is the first nursing diagnosis i came up with:
ineffective airway clearance r/t presence of secretions in the bronchi and presence of artificial airway (tracheostomy) aeb crackles in all lobes, intermittently labored breathing, and absent cough.
and for the life of me, i can't come up with another one!! i was thinking about delayed growth and development r/t the effects of physical disability secondary to acc or impaired physical mobility but sometimes i come to a block in the road when it comes to making a realistic outcome and realistic interventions that i, as the nurse, can help with (i can't just assess something or monitor something, i have to actually do something for the interventions).
could i even do something with imbalance nutrition: less than body requirements?
i've been stumped for hours now! any help would be greatly appreciated, it's definitely a tricky one with an admitting diagnosis of respiratory distress and this person also has agenesis of the corpus callosum.
thanks!!!!
