Care Plan-Stuck. Peds Mitochondrial Disorder

[miss.ky]

Hi, this is my first post. I am over 1/2 way through my 3rd semester. Graduate in December.

I have a peds pt with mitochondrial disorder and I am stuck. He is non-verbal, nonmobile, and he has a cough that is nonproductive but is making him vomit when he starts to cough really hard. He aspirated and that is why he is in the hospital. He is also having feeding tube issues r/t the vomitting and is NPO because they do not want him to aspirate again.

I have risk for infection, activity intolerance and ineffective airway clearance. I need 1 more diagnosis and I'm stuck. I also only have 4 out of 8 interventions for ineffective airway clearance.

Some other diagnosis I had thought about but I'm not sure where to go are:

Fluid Volume Deficit (though this is a probably - he doesn't have this yet)

Risk for Injury (because he is not mobile and kids w/ mitochondrial disorder are prone to seizures and they have decreased muscle tone)

Alteration in Nutrition: Less than body requirements

I think I'm thinking too much. But his medical diagnosis has me stumped. Honestly there isn't alot of specific information about it.

Thanks for any help!:heartbeat

[Daytonite, BSN, RN]

what has you stumped about the patient's medical diagnosis? are you having trouble finding the pathophysiology for your care plan? i was trying to find information about it on the nih (national institutes if health) and finally just did an internet search and found this: http://www.medicinenet.com/mitochondrial_disease/article.htm on medicinenet one of the sites that i often do go to. the information is interesting and needed to help in the formulation of the related factors (etiologies) of some of your diagnostic statements. otherwise, nursing problems (nursing diagnoses) are based upon how a patient responds to their medical problems. the signs and symptoms that they display are evidence (as in aeb, as evidenced by) of the nursing problems that they have. since a care plan is literally a summarization of the nursing problems that a person has and not all the normal and good things about them, your starting point is always with your assessment of the patient. that is step #1 of the nursing process, our problem solving tool. assessment consists of:

• a health history (review of systems) - he has been hospitalized because he aspirated his vomit from coughing too hard. has mitochondrial disorder. you didn't mention his age. in a pediatric care plan for nursing school that is an important item.
  
• performing a physical exam - no assessment data was provided. with a history of coughing i would want to have seen your assessment of this patient's lungs since they are at a risk for aspiration pneumonia. if there is a cough, are they still coughing? is it productive? describe the sputum. is the n/g tube capped off or connected to suction? if connected to suction, what is draining from the tube? describe it. since the patient is npo how are they receiving food and fluid? iv? tube feedings? are there weights and labs? are they normal or abnormal? how old is this child? was the child assessed for developmental milestones? are they behind in growth and development? on what stage of erikson's should they be in? you mention that the patient is nonmobile. what exactly does that mean? does the patient move at all or does the staff have to move the patient. describe. if the patient must be moved by staff are their skin integrity issues (bedsores)? you said the patient was nonverbal. how does anyone communicate with the patient (you never mentioned the patient's age and what they are capable of)? communication is a safety issue.
  
• assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - this is never addressed in anything you posted. adls r us. it is what we nurses do. is this patient incontinent? how do they dress and bathe? who does that for them if they cannot do it? how does the patient move?
  
• reviewing the pathophysiology, signs and symptoms and complications of their medical condition - this information is needed in order for you to compare it against what you observed in the patient. you may have missed seeing something that was important. you also need to learn about what the patient is experiencing and why:
  
  • http://www.umdf.org/site/c.dnjeklnqfog/b.3041929/k.bf32/home.htm - united mitochondrial disease foundation
    
    • http://www.umdf.org/site/c.dnjeklnqfog/b.3807499/k.3857/what_is_mitochondrial_disease.htm - what is mitochondrial disease
      
    • http://www.umdf.org/site/c.dnjeklnqfog/b.3042207/k.c54c/symptoms_of_mitochondrial_cytopathies.htm - symptoms and problems
      
    • http://www.umdf.org/site/c.dnjeklnqfog/b.3808231/k.fc52/treatment.htm - treatment
      

  [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - no medication listed. an ng tube and being npo are treatments ordered by the physician

once you have collected together all the assessment data, make a list of everything that is abnormal. all that i was able to pull from your post that was useable for care planning purposes was this information:

• non-verbal
  
• nonmobile
  
• nonproductive cough
  
• vomits when he starts to cough really hard
  
• aspirated his vomit
  

this information becomes evidence that has to be used to determine what the person's nursing problems are. i suspect there is more that you just haven't posted. from that list, these nursing diagnoses would apply (in priority order):

• ineffective airway clearance (because of having a nonproductive cough)
  
• impaired physical mobility (because of being nonmobile)
  
• impaired verbal communication (because of being non-verbal)
  
• risk for aspiration (because of history of aspirating his vomit when he starts to cough really hard)
  
• risk for infection (because of history of aspirating his vomit)
  

i also think that the patient needs to be assessed for adls and developmental stage and these diagnoses considered:

• self-care deficits
  
• delayed growth and development
  

- - - - - - - - - - - - - - -

you want to use. . .activity intolerance and alteration in nutrition: less than body requirements. there is no data to support the use of these diagnoses. to use activity intolerance the patient has to have some movement and you said this patient was nomobile. you provided no data about the patient's nutrition status, so i don't even see how there is a nutrition problem. having an ng tube doesn't mean there is a problem. it is a medical strategy to deal with feeding. you need declining weights or evidence of malnutrition to show the patient has a nutrition problem. likewise with risk for fluid volume deficit and risk for injury. what are the risk factors you have to use those? i think there are other more important issues going on that need to be addressed before using any of these. "risk for" diagnoses are anticipated problems--problems that don't even exist yet. there are already plenty of problems that are already present to focus on.

[miss.ky]

Thanks, that's alot of help! The pt is 6.

[Daytonite, BSN, RN]

milestones for a 6-year old: http://www.uchospitals.edu/online-library/content=p01063. how does he measure up? if you have room you should address it in your care plan with delayed growth and development. probably r/t effects of his disabilities or multiple hospitalizations.

[miss.ky]

milestones for a 6-year old: http://www.uchospitals.edu/online-library/content=p01063. how does he measure up? if you have room you should address it in your care plan with delayed growth and development. probably r/t effects of his disabilities or multiple hospitalizations.

thanks, what can you do with goals for a child who will likely never cognitively and physically progress?

i really appreciate your help.:nuke:

[Daytonite, BSN, RN]

thanks, what can you do with goals for a child who will likely never cognitively and physically progress?

i really appreciate your help.

support their deterioration or the stabilization of their condition. there is nothing wrong with a goal that is something like "continue to. . ." your goals have to be based on what your baseline assessment data is. that is part of the problem i was finding with the information you presented. it wasn't very specific.

also, your nursing interventions are focused on the data that support each diagnosis. just like doctors treat the symptoms of a disease, we also treat the signs and symptoms (defining characteristics) of a nursing diagnosis. ex: for a nursing diagnosis of ineffective airway clearance r/t ___ aeb nonproductive cough, the nursing interventions focus on treating and doing something about the nonproductive cough. you can see some nursing interventions for this diagnosis that may, or may not, be useable for this patient on this previous thread: https://allnurses.com/nursing-student-assistance/need-help-ncp-372845.html - need help for ncp

[rachelgeorgina]

I work with a lot of kids with varying types of mitochondrial disorders that generally manifest in the way you've described: non-verbal, non-mobile, fancy and exceptionally complicated wheelchair bound, gastrostomy fed, NPO etc.

Have you considered risk for pressure wounds, because the kid can't move, he's stuck in his chair or his bed or wherever the staff put him and is at the whim of god knows whom to turn him every two hours.

Also, while he is non-verbal and seemingly blank, he's still a person, so you'd want to consider risk for anxiety (re: coughing, aspiration, seizures) and depression (lack of adequate comfort care.)

The best things you can do for these kids is hold their hands, find something that makes their eyes light up. I have one boy that twinkles when you sneeze!

[celclt]

I have a friend whose daughter has this- she is on autism spectrum. Lots of vitamins and antioxidants.