Careplan - need a good nursing diagnosis

[Clovery]

I'm having trouble coming up with a physical nursing diagnosis for a patient. Maybe someone can help me?

I have a careplan due this week, based on a patient that I've had so far this semester. Unfortunately (for me) I've only had one patient so far because last week there were zero patients on the peds floor and the week before that I was in the ER (and I'm not allowed to do a careplan for an ER patient). This care plan is merely an "exercise" and will not be implemented - the patient is long gone. Obviously I'll have to pretend that I was there to evaluate the outcomes and such. So here's the patient:

3 month old male, born at 35 weeks. He had a fever for 2 days, mom brought him to the ER and they ran labs and sent them home. They called them back because the blood culture had gram positive cocci. Admitted the day before I was there, for rule out sepsis and UTI. They did a renal ultrasound and UA, both were normal and they were waiting on blood work to come back before discharging him, his fever was gone. So I arrived late afternoon while they were just waiting for the labs. I didn't get to see the patient much because he was very fussy and mom wanted privacy to try and nurse him to sleep. The only interaction I had was I got to do vitals on him and watch the nurse pull an IV. And I talked to the mom for a bit. The labs came back normal, and the doctor sent them home with a prescription for antibiotics, saying "He probably had a viral illness but take these just in case it was a UTI". The patient was discharged.

So my careplan has to have one physical and one psychosocial diagnosis. I started doing one for "Hyperthermia" but I felt like I was stretching things sooo much, since I have to have 2 short term and 1 long term goal, with 2 interventions per goal. Can anyone think of a better physical diagnosis? Risk for infection because of the IV? I'm really stuck because I feel like anything I do I'll just be totally BS'ing because the baby was fine by the time I saw him. My only other idea is sleep deprivation since mom said he wasn't sleeping well in the hospital but they weren't even there 48 hours so I don't know if that's long-term enough to really call it sleep deprivation. Risk for SIDS because he's a preemie? The mom really seemed on top of things - there was nothing else in the history that put him at risk.

For the psychosocial I'm going to do "Risk for caregiver role strain" for the mom, since she was stressed and very tired from staying in the hospital the whole time with a fussy baby, and she had other children at home plus she was missing work. So that should be easy enough, I hope.

Sorry if I'm missing something obvious.... any help would be appreciated!

ETA: ooops i just realized i should have put this in the student nurse assistance forum - feel free to move it. i was over here reading the care plan sticky and forgot to change over when i started the thread.

[Pneumothorax, BSN, RN]

do you have a care plan book? this is what i put together from what info you gave.

Hyperthermia r/t illness aeb disturbed sleeping pattern and gram positive cocci culture, elevated temperature of _______*F for 2 days

goal: Pt body temp will decrease by 1 degree Farenheit axillary by end of shift

interventions: 1. admin antipyretics as ordered and record effectiveness 2. use non pharmacologic methods to reduce high fever such as removing clothing, sheets,etc.

since its an "exercise" then just write it on what the kiddo came in for.

the risk for sids isnt related to his current problem..which is or was a fever for 2 days

[Clovery]

yes i have a nursing diagnosis book -Ackley.

thanks for your reply :) luckily i didn't delete the careplan i started for hyperthermia because it's pretty similar to what you have there. it just felt redundant coming up with 6 interventions for a fever that went away with some tylenol... but i guess i was on the right track, so i'll just stick with that diagnosis. thanks for the good suggestions and for helping me - i guess i shouldn't have second guessed myself.

[Pneumothorax, BSN, RN]

yes i have a nursing diagnosis book -Ackley.

thanks for your reply :) luckily i didn't delete the careplan i started for hyperthermia because it's pretty similar to what you have there. it just felt redundant coming up with 6 interventions for a fever that went away with some tylenol... but i guess i was on the right track, so i'll just stick with that diagnosis. thanks for the good suggestions and for helping me - i guess i shouldn't have second guessed myself.

yeah, youre treating the chief complaint..or something like that hehe :)