I can't find a problem in my patient @_@

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Specializes in OR,ICU,DR,Cancer,Pedia.

Every week we were tasked to make NCPs on a patient. But now I can't find a problem in my two pedia patients @__@

Patient 1

1 month old baby

LBM & Cough, oral candiasis, to consider sepsis

VS: Normal

Cardiac Rate: 145 bpm

Respiratory Rate: 35 cpm

Temp: 37 degrees celsius

Watery yellowish stool, on milk formula feeding, normal labs

Chills when covers is removed.

Add: Crackles upon auscultation

Pneumonia

Patient 2

4 month old baby

Fever, IMP: Lower Respiratory Tract Infection

cough, Bronchopneumonia in Chest X-ray result

VS: Normal

Cardiac Rate: 134 bpm

Respiratory Rate: 30 cpm

Temp: 36.1 degress celsius

@__@ I tried going for fever but patient 1 and patient 2 didn't go febrile.

Can I do ineffective thermoregulation of patient 1?

My nursing diagnosis would be: Ineffective thermoregulation related to immaturity.

or ineffective airway clearance..

Nursing Diagnosis would be: Ineffective airway clearance related to abnormal breath sounds secondary to pneumonia?

What about patient 2? He rarely coughs, not in respiratory distress, no crackles or wheezing. No loose stools. Breastfed regularly.

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

all nursing problems, which become nursing diagnoses, are always based upon the symptoms (nanda language: defining characteristics) that a patient has. you have listed a number of them in your post. what you need to do with that list of symptoms is look for nursing diagnoses (which are labels placed on nursing problems) that will match with some of those symptoms. you also need to make sure the your patient's underlying pathophysiology of their medical disease process also matches with the nursing diagnosis you are choosing, so you need to read the definition of the nursing diagnosis carefully. for this, you need a nursing diagnosis reference book of some sort to help you out. the nice thing about nursing diagnosis references is that they also list these symptoms with the nursing diagnoses so you can double check to see if you've missed one or more of them when you did your assessment. if you do not have one of these references, there are a limited number of the commonly used nursing diagnoses and the nanda information about them listed on these two websites:

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm

http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/index.php#diagnoses

one of the things that is very common among students is that their skill and competency in performing assessments is not fully developed yet. it's not your fault. it takes time, sometimes years, to become proficient in assessing patients. assessment includes not only doing a physical examination, but also doing a thorough investigating of the information in the patient's medical record. so, it is a good idea to look up your patient's medical diseases in a reference book to see what the reference says their symptoms are to determine if you missed any of these symptoms when you did your own assessment of the patient.

patient #1

medical conditions:

oral candiasis (symptoms of this that you should have seen were: cream-colored or bluish white lace-like patches of exudate on the tongue, mouth, pharynx and circumoral tissues with bloody engorgement when scraped, hemoptysis, cough, and coorifice breath sounds)

pneumonia

possible sepsis (this is a serious condition with fatal symptoms if untreated)

symptoms you found:

loose, watery bowel movements (lbm)

cough

chills when covers are removed.

crackles upon auscultation

problems (nursing diagnoses) are determined from the above symptoms:

ineffective airway clearance
(r/t secretions in the bronchi aeb
cough and crackles upon auscultation
)

diarrhea
(r/t infectious toxins aeb
at least 3 loose watery bowel movements a day
)

hyperthermia
(r/t increased metabolic rate secondary to pneumonia and possible sepsis aeb
chills
) another symptom this patient might have had that you missed was flushed skin that was warm to the touch.

patient #2

medical conditions:

lower respiratory tract infection

bronchopneumonia on chest x-ray result.

symptoms:

  • often there is no cough

  • the x-ray is usually more diagnostic

  • wheezing is common

  • low fevers (below 38 celsius)

  • there may be conjunctivitis

symptoms you found:

4-months old

fever

impacted (imp)

rare cough

breastfed

problems (nursing diagnoses) are determined from the above symptoms:

hyperthermia
(r/t increased metabolic rate secondary to lower respiratory tract infection and bronchopneumonia aeb
fever of xxx
)

effective breastfeeding
(r/t normal infant oral structure aeb
[see nanda list of defining characteristics]

constipation
(r/t ??
[could be insufficient fiber intake, could be abdominal weakness, could be a slow down of peristalsis--more information is needed]
aeb
[need more information here about the patient's bowel movements]

risk for delayed development
(r/t serious illness) - for this diagnosis you have to know what the normal developmental task should be for the child at a specific age(s) you want to target. your nursing interventions then are to assess and monitor the patient for those specific tasks that they show lacking and to report or assist in getting the caretaker knowledge or help in managing it.

do you see how you use the symptoms the patient has to merge them with appropriate nursing diagnoses? the nursing diagnoses are merely labels that are placed on problems that a patient has.

now, when you continue to work on your care plan and develop your goals and nursing interventions, they are specifically designed around the specific symptoms that fit with that particular nursing diagnosis. that is why i listed the with each nursing diagnosis and bold-faced them for you. that way everything is rationally organized in the care plan.

hope this helps you. there is more care plan information on these two threads of allnurses:

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Specializes in OR,ICU,DR,Cancer,Pedia.

Oh @_@ Really detailed there :D Thank you for your help ^^, I never thought that breastfeeding can be used for making an NCP. I missed that in the NANDA list :-) Thanks again :D

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

you are welcome. i work with the most current nursing diagnosis reference from nanda. there are currently 188 official nursing diagnoses. most students and nurses have never seen the official list--mostly because nanda does not make it free to the public. you have to pay for their current handbook or other publications to get this information. what i have given you came from the 2007-2008 handbook (nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 u.s. http://www.nanda.org/html/nursing_diagnosis.html) published by them. this is why i stress that when you are a learner, you really need to have a nursing diagnosis reference book, the more current, the better, to help you out.

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