NANDA format - Diagnosis needed

Nurses General Nursing

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:uhoh3: Another care plan due --- pt. is a 6 day old female in ped. unit on morphine sulfate because mother is a heroin and cocaine user. Baby girl did test positive for cocaine. I need to come up with 2 priority diagnosis and goals for this baby. I was thinking along the line of respiratory depression because of the morphine and possibly risk for infection? Any and all help would be appreciated. Thanks

:idea:

CCCSN

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Specializes in Nursing Ed, Ob/GYN, AD, LTC, Rehab.

I am a nursing student as well and always struggled with NANDA diagnosis until i bought a care plan book. Borders has a few in stock always, i would go buy one. Mine was 35 dollars and let me tell you the best money i ever spent! It organizes them by disease and diagnosis. Great stuff!

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Specializes in ICU.

Is there one for alterted mother-infant bonding, or something along those lines? I am assuming Mom is not there all the time.

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Risk for Alteration in comfort related to opiod withdrawal manifested by high pitched cry

Risk for skin breakdown related to loose stools associated with opiod withdrawal

Get a book, those books saved my butt in school. Good luck, a baby on opiod withdrawal is a long, hard road.

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No help to offer but prayers going up for that little girl.

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Specializes in Trauma ICU.

Try this website....they have an alphabetized list of diagnoses.

http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH6e/Constructor/

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

Why are you thinking along the lines of respiratory depression? Does the baby have any symptoms to support this? Any nursing diagnosis you use must be supported by symptoms exhited by the baby. You've listed none. You can't just pick a nursing diagnosis out of the air without supporting symptoms that you obtained during your assessment of the baby. You will find sticky threads on the Nursing Student Assistance and General Nursing Student Discussion Forum that have care plan information and help on them. You should review the posts on those threads.

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I am a nursing student as well and always struggled with NANDA diagnosis until i bought a care plan book. Borders has a few in stock always, i would go buy one. Mine was 35 dollars and let me tell you the best money i ever spent! It organizes them by disease and diagnosis. Great stuff!

Thanks for the input. I have one NANDA book and one CARE PLAN book that the college suggested we purchase last year. It just seems that all the patients we are given for reports are trickier to figure out. I will check into purchasing another care plan book. Thanks again for the help.

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

i apologize for not being able to give as an extensive an answer to your question yesterday as i wanted, but i was getting interrupted and i wanted to at least start you in a direction you should go.

when you are doing care plans for school, it is extremely important that you follow the steps of the care planning process. if you look at the first chapter(s) of your care plan books there should be information on the nursing process and care plan writing. most of these books explain how your assessment data (step #1) is used to determine nursing diagnoses (step #2). this is an extremely important concept for you to understand and nanda pushes it as well. nanda links defining characteristics with each of the, now, 188 nursing diagnoses. they are in the very same sense similar to the symptoms that define a medical diagnosis. with nursing diagnoses, however, we can be a little looser with classifying a nursing diagnosis. what i mean is you can have only one or two of the defining characteristics that are included under a nursing diagnosis and you can justifiably use that nursing diagnosis. medical diagnosing is a bit more stricter. you still have to show that use of rational, or critical thinking in putting together your nursing diagnoses on your care plans for school assignments or your grades are going to get dinged. those three and four part nursing diagnostic statements that you have to write for your care plans are supposed to do just that.

now, i am aware that nursing diagnosis books like nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig have an index at the front of them where you can look up client problems, medical diagnoses, psychiatric diagnoses, symptoms and clinical states to find nursing diagnoses. however, people forget to read the small print at the very beginning of these cross-listings. the one in ackley and ladwig states "use this section to find suggestions for nursing diagnoses for your client." what they are doing is saving you a lot of time from searching through a publication like nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international which lists all 188 nursing diagnoses alphabetically, defines them, and lists their defining characteristics and related factors--that's it. where do you start to look for the correct diagnosis if you have no clue as to what your patient's symptoms are going to end up being as a nursing diagnosis? nurses, such as ackley and ladwig saw the problem this was creating for people just learning nursing diagnosis (i.e., students) and came up with the cross-index that is in their book. this same cross-index is on their online care plan constructor companion to the book i mentioned above which traumaicurn gave you a link to. actually, there is a more updated version of the constructor at this site: [color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/ and i have posted links directly into the individual nursing diagnosis pages on the contructor on both of these threads where you can get outcomes (goals) and nursing interventions for 75 nursing diagnoses:

the point i am making is this: those kinds of indexes are only pointing you in the direction to go. you still have to do the legwork with regard to showing the relationship between the actual symptoms your patient has to the nursing diagnosis itself. this involves knowing and understanding the definition of the specific nursing diagnosis involved, the defining characteristics (these are the abnormal data assessment items you found during your data assessment part of the nursing process) and the related factors. when it all fits together, developing the goals and nursing interventions just flows from it all in a nice rational way.

now, you have a little baby of a mother who is a heroin and cocaine user who tested positive for cocaine and is on morphine sulfate. the first thing you should do is hit the books for information on how current heroin and cocaine use affects a developing fetus and what kinds of physical assessment signs you should (have been) look(ing) for in this baby. it's going to help jog your memory as to some things that i'm betting you did observe, but didn't realize that they were actually abnormal assessment items that you should have included in your assessment. so, you need to do that. i think that is going to open up a few more potential nursing diagnoses for you to use on this care plan. also, when you are assessing a patient, keep in mind that we are nurses and going back to basic nursing we are concerned with how people get the activities of daily living (adls) accomplished. that includes such things as eating, peeing and pooping, moving around, sleeping, etc. now, you've hinted that this baby is on morphine and may have respiratory depression. i asked in my other post how you know this. what i was getting at is what are the assessment signs or symptoms you are seeing of this. if this baby has central nervous system depression, i'm also thinking that the respiratory system isn't the only body system that is depressed in this baby. that means that other body systems are depressed as well, so the baby is probably not sleeping or eating normally. what are the symptoms of these depressed body systems? you may have to look this information up and rethink your assessment of the baby because you may have missed a few things that are going to make a big difference in putting together a good care plan. how are the baby's nutrition needs being met? breastfeeding? bottle feeding? and, are there any problems with feeding? what about movement? if the baby has cns depression from the morphine drip, is it moving? is there any skin breakdown? with iv lines these little ones are susceptible to infections from the invasive lines just like any adult, and probably more so because their immune systems are not that well developed yet. and, what about the normal stages of development that a newborn should be experiencing? is this child already experiencing any lags? what about mother/baby bonding?

are you getting any ideas from my thinking here? you are not going to find these things in your care plan books all the time. you have to look at what is going on with your little patient and think about why things are being done and what can go wrong. babies are not a whole lot different from adults except that they are smaller. they still come with many of the same problems and a few that are based upon their age, size and level of development. but, the point i am making is that much of this is coming from assessment.

the goals for this care plan determine the direction you want your nursing interventions to take. in other words, after performing the nursing interventions, you hope to achieve your stated goals. your nursing interventions address the symptoms, or defining characteristics which you found during your data assessment. it's all related and becomes one big cycle. i hope that gives you some direction in how to approach this.

here are some links to information that i felt might be helpful:

http://www.fpnotebook.com/psy140.htm - cocaine abuse in pregnancy - includes the effects on the baby and a direction to go in looking for signs and symptoms

http://www.fpnotebook.com/nic13.htm - items to address in the examination of the newborn - each are links to pages of more information

http://www.fpnotebook.com/psy36.htm - signs of drug withdrawal

http://www.fpnotebook.com/psy32.htm - substance abuse evaluation. although this is mostly for adults there is some information here that may apply to a newborn

http://aboutheroin.org/index.php - information about heroin and withdrawal

http://www.addictionca.com/index.htm - narconon. click on "drug info" to get specific information on individual illegal drugs

http://www.addictionca.com/drug-use-pregnancy.htm - drug use during pregnancy

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along with Daytonites usual helpful suggestions, even if you don't have symptoms yet of a problem your instructor may want to know that you know that they are possible problems so you might want to do a "risk for" diagnosis for really important issues even if the baby is not showing s/s related to that problem presently.

example

Risk for ineffective breathing r/t decreased LOC or ______ secondary to opiod induced CNS depression.

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now I'm finding that even using the word "possible" is causing confusion

{for me} because in one handbook of nursing diagnoses, in its explanation

says "if you suspect a problem but have insufficient data, gather the additional data to confirm or rule out the diagnosis. If this additional data collection must be done later or by other nurses, label the diagnosis possible on the care plan or problem list."

I was using "possible" to mean - potential, that something could happen (not that it was suspected) - therefore to teach or alert the patient, in order to prevent a potential problem

What is the proper terminology?

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at risk for? I don't know, I am still struggling with this myself

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