Nursing Process Paper- pediatric "risk for" diagnosis- PLEASE HELP!

your assignment is called a nursing process paper for a reason. it is because you are to follow the nursing process in reaching the nursing diagnosis, client outcomes, nursing interventions, and evaluation of the plan. it helps to review what the nursing process is and how it works with care planning. the nursing process form you were given is to help you organize all the information you were given and what you will add to it. it doesn't matter that the information that this mother gave is incomplete. care planning is about finding the patient's nursing problems and then developing strategies to do something about them. you work with the information you have. this typically happens in the real world.

if you are not a regular reader of my care plan postings, this is my suggestion of how the steps of the nursing process should be used to care plan and it should be followed in this sequence so you stay focused and on target:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
   • a physical assessment of the patient
     
   • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
     
   • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
     
   • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
     
     • use: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites
       

[*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

• your instructors might have given it to you.
  
• you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
    

[*]planning (write measurable goals/outcomes and nursing interventions)

• goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  
  • improve the problem or remedy/cure it
    
  • stabilize it
    
  • support its deterioration
    

  [*]how to write goal statements: https://allnurses.com/forums/2509305-post158.html

  [*]interventions are of four types

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    
    • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
      

    [*]care/perform/provide/assist (performing actual patient care)

    [*]teach/educate/instruct/supervise (educating patient or caregiver)

    [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

now, not everything in the above outline will be appropriate to do for a case scenario where you have been presented with information already. you can't do a physical assessment, for instance. but, lets work through this step-by-step in an organized fashion and see what shakes out.

step 1 assessment - you are specifically asked to separate subjective and objective data - when care planning you are specifically looking for abnormal data - i will let you fill out your form with all the data and classify it as subjective or objective - for care planning (problem solving) we are only interested in what is not normal and what the doctor has treated since that is targeted medical signs or symptoms and we're interested in that too. i want to see them in a list along with the patients medical conditions.

• frequent otitis media with febrile seizures
  • medical treatments
    • diazepam rectal gel - i would look up the side effects of diazepam (neutropenia, respiratory depression) which puts him at risk for respiratory infections
      
    • tubes in both ears

  [*]speech was understood by mother, difficult to understand by unfamiliar listener

  [*]engages in daily play

  [*]living below the federal poverty level

  [*]bp= 80/150 - is this correct or a typo? this is a very high b/p for a 4.5 year old child. this is a high b/p for an adult. this is a b/p that is critically high, especially the diastolic!

step #2 determination of the patient's problem(s)/nursing diagnosis - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

• if there is, indeed, a critical hypertension issue going on, the diagnosis would be decreased cardiac output r/t altered contractility aeb b/p of 80/150
  
• impaired verbal communication r/t learning deficit aeb speech that is difficult for others except the mother to understand.
  • this child has probably not learned to speak correctly because of his many early childhood ear infections which caused temporary interference with his hearing. if you read about how children learn language, hearing is a necessary part of that cycle which was impaired during this child's early years. children learn to speak by hearing others. deaf people do not talk like others because they have never heard others actually speak so they have no reference to mimic and something similar is probably what is happening with this child as well.
    
  • http://www.merck.com/mmpe/sec19/ch299/ch299a.html

my diagnosis (doesn't have to be highest priority): risk for delayed speech and language development r/t otitis media.

subjective/objective data: is diet subjective? b/c mother reported and we can't measure?

speech info- subjective or objective?

client outcomes?

plan implementation- can i say something about needing more info?

evaluations/continuing outcomes

hope that helps.

Please tell me the B/P was just a typo. When I saw that I almost fell off my chair over here. I didn't think it was related to the diazepam, but I doubled checked just to make sure. It's like it is just sitting there out of the blue with no other clues or symptoms to relate it to. If it is really a true symptom, the more I think about this, the little boy is a Risk for Injury (stroke).