Need help with care plan & interventions - congential heart problems

Daytonite, BSN, RN · Feb 4, 2008

you cannot do anything with nursing diagnoses for a care plan until you do the preliminary work first. you must follow the nursing process sequence:

assessment (collect data from medical record, do a physical assessment of the patient, look up information about your patient's medical diseases/conditions)
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 diagnosis to use)
planning (write measurable goals/outcomes and nursing interventions)
implementation (initiate the care plan)
evaluation (determine if goals/outcomes have been met)

before you can go about choosing any nursing diagnoses for this patient you must gather your assessment data. this is a huge activity that you cannot fluff over. it involves a number of things. your physical assessment, of course. you should also include abnormal data that you collected from the patient's medical record (chart). there are also observations that you made as you went about performing care for this patient. in addition, you also need to look up information about this patient's medical diseases/conditions: hypoplastic right heart syndrome, atrial septal defect, pda litigation, bt shunt, and hypoxia. the reason is because the pathophysiology of some of these conditions will be needed in forming your 3-part nursing diagnostic statements in step #2 of the care plan (nursing process) when you get to the "related to" part (related factors). it also helps to look at the textbook signs and symptoms of these medical conditions to make sure that you didn't miss any of them in assessing your patient. if you find that you did, then you merely need to add that symptom to your assessment information.

once you have completed all the above, only then can you move on to the next step of the nursing process which is why you posted--nursing diagnosis. step #2 of the nursing process is the identification of the patient's problems. the nursing diagnosis is merely a shortened label of the patient's actual problem. the patient's problem is more clearly stated if you read the definition of the nursing diagnosis. you will find these definitions in care plan and nursing diagnosis books that have included nanda information. there is also some nanda information posted on the internet in limited quantify.

now, some words about diagnosing. a diagnosis is the resulting decision or opinion that one makes after the process of examination or investigation of the facts. in the case of nursing diagnosis, your "facts" are the list of patient signs and symptoms that you are now going to make from your assessment activities in step #1 of the nursing process. every nursing diagnosis, just like every medical diagnosis, has an accompanying list of signs and symptoms. in order to assign any nursing diagnosis to a patient they must have at least one if not several of those signs and symptoms. and, in fact, in your 3-part nursing diagnostic statement your "aeb" items are going to be just that--the signs and symptoms that are going to support your use of that nursing diagnosis.

the only symptoms you actually listed for this child were:

hypoxia
satting at 86%-92%
coughing
shortness of breath

since peds is not my field of practice i really am not familiar with the signs and symptoms of this child's medical conditions. however, the hypoxia and sats of 86% are symptoms of impaired gas exchange. your nursing diagnostic statement should be something like this: impaired gas exchange related to ventilation perfusion imbalance as evidenced by hypoxia and o2 sats of 86%. here is a link to a webpage that includes nanda information as well as nursing interventions on this: [color=#3366ff]impaired gas exchange. but, i am also thinking that if this patient in on a ventilator you can also use impaired spontaneous ventilation due to the sats of 86%, but other symptoms of this diagnosis include use of accessory muscles to breathe, dyspnea and increased heart rates.

the coughing and shortness of breath are symptoms of ineffective airway clearance. your nursing diagnostic statement should be something like this: ineffective airway clearance related to excessive mucous [or whatever etiology you know to be true here] as evidenced by coughing and shortness of breath. here is a link to a webpage that includes nanda information as well as nursing interventions on this: [color=#3366ff]ineffective airway clearance.

when one is diagnosing it is a good idea to use a nursing diagnosis reference of some sort to make sure you are diagnosing correctly. most of the current care plan and nursing diagnosis books in publication today have the nanda taxonomy information is them. i use nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international which is the bare bones information about each of the current 188 nursing diagnoses and includes the definition, symptoms (nanda calls them defining characteristics) and underlying etiologies and causes (nanda calls them related factors) for each.

once you have your nursing diagnostic statements in place, then you can move on to step #3 which is to develop your goals and nursing interventions for those signs and symptoms that this patient has.

do not dwell on the nursing diagnoses. spend more time developing that list of the patient's signs and symptoms because your entire care plan is based upon them. if they are not rock solid, neither is your care plan.

qstick7 · Feb 7, 2008

Hi there- Basically it sounds like this patient has been made into a single ventricle, so that would mean that her sats are never normal because the blood flow to the lungs is solely dependent on the BT shunt and the mixing of blood at the atrial level. Normal sats for this patient should be 75-85%. Hope this helps. It sounds like a URI, and with the SOB and coughing, the patient in respect may be 'overcirculating' and should not need O2.