Published May 1, 2008
ryze21
16 Posts
it was also the chief complaint.
Daytonite, BSN, RN
1 Article; 14,604 Posts
What have you done on this care plan so far?
I have only the assessment he has swelling of face, stomach, legs and feet . the BP is 100/60, RR is 44, Temp is 36.8 and Pulse is 120. he is 1 year old.
if that is all you have to work with then that is all you have to make your nursing decisions on. i'm hoping you did a developmental assessment. was there no crying, fever or other symptoms? what did the doctor order for this child? surely, this child isn't taking up hospital space and just lying around. what does the doctor think is wrong with him?
present illness started 7 days. cephalexin was discontinue but still persisting productive cough with accompany undocumented low grade fever.5 days there is swelling of face stomach legs and feet. They consult at nearby hospital, urinalysis, CBC and chest X ray and the admitting diagnosis was pneumonia prescribed with carbocisteine 66ml a day and clarithromycin 17.6 ml a day. Facial edema was resolved but there is still edema in lower extremities. 1 day to consult pediatrician admitting impression was allergy prescribed with centrizine and relestal dosage unrevealed. Edema did'nt resolved.
although the doctor says that generalized edema was the chief complaint, that is not the main nursing problem(s). a medical diagnosis of pneumonia in a child is pretty serious.
you use symptoms to determine nursing problems. this patient has symptoms of a productive cough, low grade fever and swelling in the lower extremities. these are nursing problems that you canm turn into nursing diagnoses and there are nursing interventions for them. that is what you will focus your nursing care plan on.