Having a complete brain fart with this peds careplan!

[mistiffy]

Well, I haven't been on here in a really long time. The last time I posted I think I was in my first semester and now I'm halfway through my third, only one and a half more to go:yeah:!!! lol

I am doing a careplan for a 14yo female that developed a pelvic abcess one week after a lap appy. She was in a lot of pain, rated an 8, winced with any kind of movement, and cried when ambulating to the bathroom and moving from bed to chair. Oh, and I should mention she had a drain placed to drain the abcess, which is where all her pain was coming from. Older sib was with pt as her and pt's parents and one other sib were taking turns staying at the hospital with pt. The pt at first refused to take pain med (morphine) and didn't want to move at all, was just lying in bed, because she said as long as she remained still, she didn't hurt. The older sib then told me and the RN that their family didn't really take meds when they were in pain due to fear of making them sick and addiction. So, teaching was done regarding this by myself and the RN and the pt. requested the morphine not too long after that. Upon initial assessment, the abdomen was slightly distended. Pt also ran a temp of 99.4 at 0830 and at 1130 temp was 100.4. Pt was also NPO per dr's orders and extremely nauseated, cried to me at one point that she felt like she needed to throw up so bad, but couldn't (zofran was given IVP). Pt was also on IVF D5 with 20mEq K, Ciprofloxacin IVPB. After the morphine and zofran were given, pt stated she was feeling better and was smiling and asking questions. Also some abnormal labs: BUN-7, Creatinine-0.56, Albumin-3.3, AST-44, ALT-94, WBC-15.9, Hgb-10.3, Hct-32.6, MCV-65, MCH-20.5, RDW-16.8, neutrophils-69, lymphocytes-14

So, here is my dilemma: I have to come up with 7 problems (nursing dx), and I can only come up with 5:crying2:! We only have to work up the priority 3 with interventions, but gotta list 7 on our prob list with supporting data. I think I'm just overthinking it or something. So this is what I have so far:

-Acute Pain r/t (altered tissue integrity, surgery, illness??)

-Infection r/t (surgery, acute illness)

-Knowledge Deficit r/t verbalization of incorrect knowledge regarding pain medication (I know there's gotta be a better way to word that, but like I said, brain fart)

-Anxiety r/t administration of pain medication, pain associated with movement

-Impaired Tissue Integrity r/t altered circulation, tissue disruption

I also had thought about risk for deficient fluid volume r/t (decreased intake, nausea) but wasn't for sure if I could use it due to the NPO status.

Any suggestions/help :twocents:would be GREATLY appreciated! Thanks!!!!!!

[NotReady4PrimeTime, RN]

When a patient is febrile there are increased insensible fluid losses. And if she did even manage to vomit, she'd lose fluid there too. So there is a potential for fluid volume deficit even though it wouldn't be a priority nursing diagnosis.

Another possible choice could be activity intolerance related to reluctance to move secondary to pain, self-care deficit also related to reluctance to move, altered individual coping related to pain and cultural/familial influences, body image disturbance related to presence of pelvic incision and drain in adolescent female... wow, I haven't done a nursing care plan in 15 years so I'm surprised I came up with those.

[Daytonite, BSN, RN]

some diagnoses i would consider. . .

• delayed surgical recovery r/t post operative surgical site infection aeb delayed healing of surgical wound and difficulty moving due to pain
  
• fear r/t fear of unknown and of painful procedures
  
• deficient diversional activity r/t separation from peers and monotony aeb [boredom]
  
• risk for infection r/t perforated appendix [this is specifically a risk for systemic sepsis and interventions would be to prevent sepsis]
  
• risk for compromised family coping r/t exhaustive supportive capacity of significant people
  
  

acute pain r/t (altered tissue integrity, surgery, illness??)

one week post surgery her acute pain is because of the inflammatory response as a result of the infectious process that is going on. all infection has the inflammatory response occurring first. the cardinal signs of inflammation are: redness, heat (fever), swelling and pain. the correct wording for this diagnosis should be

acute pain r/t inflammation of surgical site aeb pain rated as 8 on a scale of 0 to 10 and refusing to move to avoid pain.

infection r/t (surgery, acute illness)

infection is a medical diagnosis. are you sure you can use

infection

as a nursing diagnosis? most students would be told to break down the symptoms of the infection into a list and see what nursing diagnoses could be made from them. since she has been having fevers of 99.4 and 100.4

hyperthermia

can be diagnosed. i would diagnose

hyperthermia r/t inflammation of surgical site secondary to pelvic abscess aeb fevers of 99.4 and 100.4.

knowledge deficit r/t verbalization of incorrect knowledge regarding pain medication (i know there's gotta be a better way to word that, but like i said, brain fart)

the topic of the

deficient knowledge

must be specified in the diagnostic title. the reason (cause) for the lack of knowledge is cognitive because this is a behavioral diagnosis. the correct way to word this diagnosis is

deficient knowledge, pain medication r/t lack of information aeb patient's verbalization of incorrect information regarding fear that taking pain medication would make her sick and addicted.

anxiety r/t administration of pain medication, pain associated with movement

anxiety

, the nursing diagnosis, is

vague uneasy feeling of discomfort or dread generated by perceptions of real or imagined threat to one's existence.

i am not getting where this patient was having anxiety unless you are hinting that she didn't want to be alone which is why she wanted someone from her family to stay with her all the time. i'm not sure that is

anxiety

. why not call that

fear

, the cognitive problem?

anxiety

has very specific physical symptoms. you can see the long list of them posted on these nursing diagnosis pages (see the defining characteristics):

• http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=03
  - anxiety
  
  
• anxiety
  
  

the r/t factor for the nursing diagnosis of

anxiety

needs to be some threat, crisis, conflict, unmet need or a fairly dramatic life change. i just don't see "

administration of pain medication

" or "

pain associated with movement

" as being the underlying factors of her

anxiety

. people with anxiety have physical symptoms of it.

impaired tissue integrity r/t altered circulation, tissue disruption

impaired tissue integrity

is about the physical damage to integumentary and subcutaneous layers of skin. "

altered circulation

" causes perfusion problems which is a whole other problem (

impaired tissue perfusion

). "

tissue disruption

" just restates the problem and hasn't told us anything about the etiology (cause) of this

impaired tissue integrity

. what caused this

impaired tissue integrity

? the surgeons cut into her. so, the diagnosis needs to be written as

impaired tissue integrity

r/t surgical intervention aeb

[description of the surgical wound]. but there is a new problem here and that is that the surgery happened a week or so ago. she now has a postop wound infection, so her healing is delayed. there is a specific diagnosis for this that will cover the wound infection and resulting pain--

delayed surgical recovery

.

the 3 diagnoses i would chose as the top 3 in priority would be:

1. delayed surgical recovery r/t post operative surgical site infection aeb delayed healing of surgical wound and difficulty moving due to pain
   
2. acute pain r/t inflammation of surgical site aeb pain rated as 8 on a scale of 0 to 10 and refusing to move to avoid pain.
   
3. deficient knowledge, pain medication r/t lack of information aeb patient's verbalization of incorrect information regarding fear that taking pain medication would make her sick and addicted.
   

[mistiffy]

WOW, thank you both so much! I have been working on this careplan since I posted that first message earlier today, lol. Daytonite- I have been going back and forth on whether to use the infection dx or not (several of my professors have told me this semester I could use that, which is why I was leaning towards it in the first place), but I have to say I just looked up the delayed surgical recovery dx and I like it much better!

I don't know why I had so much trouble with this careplan, so thank you all so much for the help, I REALLY REALLY appreciate it!

[Daytonite, BSN, RN]

When you've done as many care plans as I have you get to know the different nursing diagnoses. There are still a few I've never used that surprise me sometimes when I come across them. When you are new at this, everything is a surprise, isn't it? :chuckle

[Krisymof2]

Don't forget Imbalanced Nutrition r/t NPO status.

[Daytonite, BSN, RN]

don't forget imbalanced nutrition r/t npo status.

i don't recommend that students use this etiology of npo status with this particular diagnosis. npo status is a medical treatment. it is not in the spirit of the definition of the diagnosis and i have seen many nursing instructors ding it as being an incorrect etiology. nanda specifically lists the related factors for this diagnosis as being things that interfere with the normal intake of nutrition. npo as an ordered treatment does not explain the physiological cause of the imbalanced nutrition.