Help!! I don't want to fail in my 4th semester over a CARE PLAN...

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Hi, I've been reading posts on this site for over a year now. I have never actually posted anything myself!! I'm in my 4th semester and stuggling with this care plan. I have done well with them up to this point but I'm truly stumped...My assignment is to list 2 priority nursing dx's...Ok...god I hope someone can help me..I'm praying!!! Anyways here's my client...

3 year old F - Admitted r/t respiratory distress...RSV came back positive. Pt has Hx of IgA defieciency and mild Asthma and obstructive sleep apnea (on Bi-Pap at home). She had a fever upon admit of 101.4 but now is steady at about 99.0. Clear breath sounds, no retractions, rate is @ 40 and regular. BP is WNL and HR is @ 126. She was placed on contact isolation r/t RSV and also placed on neutropenic febrile guidelines. She has a hep-lock but no IV fluids are running or have been ordered. She ate 10% of her breakfast and her intake was 580 output was 180(6 hour time period). Her WBC is low @ 2.0 with neutrophils @ 306u/L, her K+ is at the lower end @ 3.4. No ABG's were ran on her. She is on Cefepime (Cephalosporin-makes no sense because viral infection)...and on Albuterol...new orders are for pulmicort and singulair...Also a strict I & O has been placed.

My first Dx is Ineffective Breathing Pattern r/t inflammation of the lungs secondary to infection a/e/b respirations at 40. or r/t increased work of breathing and decreased energy...

I want to do Impaired Gas exchange but dont have any ABG's!! My teacher said I couldnt do Risk for Infection r/t compromised immune system..(I was thinking because of her IgA deficiency)...my teacher said that was not appropriate and to look at my DATA!!...

Other ideas I have are: Risk for fluid volume deficit r/t inability to meet body requirements and increased metabolic demand

My question is...Ive never done a Risk for...The doctor hasnt even diagnosed this yet....should I be concerned r/t the above values and take the initiative to implement this ASAP?

Thanks to anyone who can give me some advice.........

WK:nurse:

......Risk for Hyperthermia r/t

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

They are concerned about her immunity. There is a nursing diagnosis for this: Ineffective Protection R/T leukopenia AEB fluctuating fevers and impaired immunity

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Hi Dayonite...

I've seen your name on here a lot with great advice...thank you so much for responding!! Do you think that my Ineffective Breathing is the other priority? What do you think are the top 2 priorities?...Wendy

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

  1. Ineffective Breathing
  2. Ineffective Protection

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Thank you Dayonite for responding!! :yeah::yeah::yeah::idea:

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Thanks again...I actually even borrowed a great care plan book from one of my fellow OSU classmates!!! Go Buckeye's !!!!

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