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I have my major paper due this week for peds. Its a care study of our choice the past 3 weeks. I'm doing mine on pediatric osteomyelitis. My pateint was a 1 y old boy with this cond. on his lower leg. I have the majority of my paper done (patho, survey, safety, diet, ect.), but now I have to finish it with a nursing diagnosis and care plan. I thought no problem, I've done a few of them last semester, but I think I'm out of practice now. This is different too. I'm not sure if we are supposed to do the list of ineffective behaviors and causes, comprehensive list of nursing dx, then the care plan like we did last semester. Or just state the diagnosis and then do the care plan on the main diagnosis? My book lists Acute pain related to biologic injury, Impaired Physical mobility related to discomfort, Risk for inf. (sepsis) related to spread of infection, Risk for imb. nutrition R/T loss of apetite, and Health seeking behaviors R/T lack of info about disease processes. I'm thinking Risk for infection or maybe acute pain as the main ones. Does that sound good or any other direction I should go?

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Specializes in med/surg, telemetry, IV therapy, mgmt.

You've got a patient with osteomyelitis. Forget what your care plan book says about osteomyelitis for the moment. What are the symptoms your little patient had?

  • Pain?
  • Swelling of the affected area?
  • Erythema or open draining wound?
  • Fever?
  • Any dehydration?
  • Refusing to eat?
  • Problems with mobility?

Nursing diagnoses are ALWAYS based on the symptoms, or defining characteristics, that the patient is exhibiting. ALWAYS, ALWAYS, ALWAYS!

  • Is there some kind of an open wound here? If so, you can use Impaired Skin Integrity.
  • If your patient wasn't eating well, and this is common with children who are very ill, then use Imbalanced Nutrition: less than body requirements R/T loss of appetite.
  • If the patient also was dehydrated you need to use Deficient Fluid Volume R/T loss of appetite and not eating. Ill children dehydrate very rapidly and run into electrolyte problems very rapidly.
  • If this child had a fever you can use Hyperthermia
  • If your patient had difficulty moving walking around because of the myelitis, wound or pain, then use Impaired Physical Mobility R/T pain and discomfort.
  • If your patient had pain, then you can use Acute Pain.
  • Is a one-year old really going to be actively seeking ways to improve their health? I don't think so. So, Health-Seeking Behaviors is really not a plausible nursing diagnosis to use with this patient.

The "Risk for" diagnoses are for things that don't even exist. You have a ill child here with symptoms (which you really haven't mentioned) that you should be able to find a nursing diagnosis for without addressing a contemplated problem.

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Your right, the main dx would have to be either acute pain or impaired skin integrity, since he did have an open sore. I'm not sure, but I think they took a sample or aspirated it. There was an x-ray that said nondisplaced fracture of distant fibular metadiaphysis. His symptoms: WBC 20H (norm 5.5-15) (I'm not sure what the H stands for), surgical inc., pain (my instructor said to put it at a 3-4 since he can't talk, but does start crying if we touched his leg, thats about all the ineffective behaviors I have for him. In my book it says something about erythrocyte sedimentation rate (ESR) elevation related to the degree of infection, but I'm not sure what that stands for as I do have a few other lab results, but not that one...

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Specializes in med/surg, telemetry, IV therapy, mgmt.

i sequenced the listing of possible nursing diagnoses in the order of priority if you were to use any of them. impaired skin integrity should be the first listed. it goes with the seriousness of the medical diagnosis and reason for admission. yes, they would have done a culture and sensivity of any would drainage in order to determine (1) if there was an infecting organism and (2) what antibiotic would be effective in treating that organism.

the labwork you've listed relates to the infective process going on. this kid most likely does have some kind of infection with a wbc of 20. the "h" next to the 20 stands for the word "high". is is merely pointing out to anyone reading the test results that 20 is an elevated, or high, wbc level. normal is 5 to 10. esr is the erythrocyte sedimentation rate and for a child the normal is about 10mm/hr. esr tends to increase when there is infection present because of the increase in plasma proteins in the serum portion of the blood due to the infection process. this leads to the ability of red blood cells to settle and separate out from the plasma part of blood more rapidly. it is a non-specific test and not one that doctors can rely on to say exactly where an infection in, only, "yes, there is an infection going on". the esr rate will rise and fall with the extent of infection present, so as the infection starts to clear with antibiotic therapy, the esr rates will improve.

http://www.medicinenet.com/complete_blood_count/article.htm - wbc

http://www.labtestsonline.org/understanding/analytes/esr/test.html - esr

assessing pain with kids is difficult because unlike an oriented and alert adult they can't tell you the specifics you want to know. they are limited by their knowledge of language. so, you have to go with observation. there are several tools that are used to assess pain in children and those who do not speak the same language as the person assessing them. one is the "faces" chart. as your instructor pointed out, crying is one way of knowing the patient is in pain.

i'm putting these links here so you can look at them and possible include information about these rating tools as nursing interventions for your case study under your acute pain diagnosis.

http://www.medicine.uiowa.edu/igec/tools/pain/faces.pdf faces pain scale - originally developed for use in pediatrics. consists of a series of seven facial expressions representing increasing degrees of pain. patients simply indicate which face represents the intensity of their current pain. it does not include a verbal component, so it may also be used for individuals with language impairments or who have trouble expressing themselves verbally. this particular tool has pretty crummy looking faces. i've seen better ones that are done with smiley-type faces.

http://www.medicine.uiowa.edu/igec/tools/pain/painthermometer.pdf the pain thermometer assesses pain by asking patients to indicate the intensity or severity of their pain on a diagram of a thermometer. it is a version of a verbal descriptor scale that visually represents increasing degrees of pain along the thermometer. adjectives describing pain (ranging from "no pain" to "pain as bad as it could be") correspond to different points on the diagram. the pain thermometer can be used for patients with moderate to severe cognitive impairments as well as for patients who have trouble with verbal communication.

information for your nursing diagnoses:

impaired skin integrity

[color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_063.php

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=48

acute pain

[color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_052.php

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=40

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Thanks Daytonight. I thought I was done, but asked my gf about my dx (she's also a nursing student and very smart) and she said I could'nt put impaired skin integrity R/T mechanical factors 2º surgical incision AEB open draining wound on lower right leg, since I don't know for sure that he had surgery. The wound was open without sutures. I wonder if I could change the 2º to biologic factors? She also said that the instructor said that pain is always the first dx. If thats the case, I would need to redo the care plan. I'm running out of time as I need to go to work, but then I will have a couple hours to finish it before going to bed tonight...

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Specializes in med/surg, telemetry, IV therapy, mgmt.

how about impaired skin integrity r/t mechanical factors secondary to traumatic physical injury aeb open draining wound on lower right leg? it sounds like the cause of the open wound is most likely from an accident.

in using maslow to prioritize a patient's needs, pain is not a priority over impaired skin integrity. the reason is because the physiological needs for the healing of a large open wound, as your patient has, include proper circulation so the tissues get adequate oxygenation and nutrition in order to heal. oxygen and nutrition are the top two needs on maslow list of physiologic priority. the attention to pain comes under the need for comfort which is at the bottom of maslow's physiologic needs. drug the patient up so his pain is relieved. but, if the basic needs of the infected and injured cells and tissues are not supported so there may be improvement or stabilization the patient will develop massive sepsis and die. there won't be any need for pain medication at that point. pain will subside as healing occurs. the wound/the infection are the underlying cause of much of this patient's troubles.

you need to do whatever your nursing instructors are directing you to do, not what i or anyone else tells you. i give my advice based on what is most commonly used in nursing practice. however, if your instructors have given you different guidelines to use in putting a care plan together and determining the priorities of the nursing diagnoses, then that is what you should go by.

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