Careplan help?

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'ello, guys! I need a bit of help on a peds careplan.

I had a patient who was 4-days old and was there for jaundice. I have two nursing diagnoses of "Risk for dehydration related to phototherapy" and "Risk for thermal injury related to phototherapy". I need to find a way to add "as evidenced by" to these, but how do I provide evidence for a *risk factor* for a patient who cannot communicate?

She also wants me to add objective and subjective data. Like if I had a patient that was in pain and was making faces or telling me they were in pain, that'd be subjective data. I have NO idea how to add subjective data for these nursing diagnoses. She said the caregivers could be used as a source of this data, but by the time I saw the patient, they had already received all of the phototherapy treatments, and was about to be discharged. I know this isn't the best patient for a careplan, but I had no other patients. (It's a very slow unit).

Any ideas on how to work with these diagnoses? :L I have to expand the two most urgent diagnoses, which were these, so unless I can figure out a more serious nursing diagnosis to expand upon, I have to work with these two.

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Specializes in Public Health.

Why are you using risk for diagnosis? And to my knowledge, you can only have risk factors when using this type of nursing diagnosis.

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If you are only at risk, there is no evidence to include an as evidenced by...

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There were a few "at risk" diagnoses in the NANDA list. See:

http://www.kc-courses.com/fundamentals/week2process/nanda2012.pdf

I couldn't think of anything more serious. :L The kid is otherwise fine.

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I'm thinking the same thing! That's why I'm stuck. Gah!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

What semester are you? What care plan/NANDA resource do you use?

care plans are all about the assessment....of the patient. You have a nursing diagnosis....You can use "Neonatal jaundice" it's an actual NANDA 2012-2014 nursing diagnosis.

Readiness for enhanced Knowledge of information on assessing jaundice when infant is discharged from the hospital, when to call the physician and possible preventative measures such as frequent breastfeeding.

Under Hyperbilirubinemia:

Disturbed Senory perception: visual (infant) r/t use of eye patches for protection of eyes during phototherapy.

Parental role Conflict r/t interruption of family life because of care regimen.

Risk for disproportionate Growth: infant r/t disinterest in feeding because of jaundice-related lethargy.

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We can use any NANDA resource. It just has to be "from the literature". I'm finishing up my junior year. We have to have 5 nursing diagnoses BUT we only expand upon the two MOST SERIOUS ones. So although neonatal jaundice is a nursing diagnosis (and I do have it in my careplan), it is not one of the two most urgent ones so I can't expand upon it. Risk of dehydration and risk of thermal injury are the two most serious ones out of the five, so I have to expand those. However, I'm having trouble expanding upon a risk opposed to something that is already happening. I could even get subjective data from a parent for an actual symptom (expressing worry and such), but nothing has "happened yet", so there's no subjective data/evidence (that I can think of) to back it up. Does that make any sense?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

nut a risk has no real subjective data as it has not occurred yet that is why it is a risk.

Did the Mom express any apprehension about feeding at home of lethargy of the baby? Ask for education aobut the babies needs once home? like Readiness for enhanced Knowledge of information on assessing jaundice when infant is discharged from the hospital, when to call the physician and possible preventative measures such as frequent breastfeeding.

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It's a risk because of phototherapy. The heat and lights pose a risk for dehydration and thermal injury. Those diagnoses are the most urgent even if they haven't occurred yet so I have to expand upon those. By the time I met with the patient and his family, they were about to be discharged. I basically did my assessment, weighted his diaper, answered some basic questions about care, and they left.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

How is risk for thermal injury most important at discharge. That actual need would be how to watch for jaundice at home and how to face the challenges of a sleepy baby, feeding, the importance of what to do it the jaundice worsens at home and what to look for. If the baby is going home they are no longer under the bili lights.

The greatest risk right now is the worsening of the Jaundice going home and the parents not knowing what to do and look for.

I'm confused...:wacky:

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