need some help/guidance with a peds care plan

nurseprnRN, BSN, RN · May 26, 2013

Sounds pretty decent from here, but I'm in the camp that merely doing an assessment activity is not an intervention. The way you justify it is by saying what you plan for various potential findings. I mean, if you're looking at, say, a kid with oxygenation issues and she gets out of breath easily, you don't just monitor her sats and see how fast she desats with activity. (or ABGs-- you're not going to be getting ABGs all the time.)

You then plan to pace her activities, break up things into small pieces so she doesn't get outta gas: you titrate her workload to her sats, and then you communicate what you learned and observed to the parents so they can do the same. Does that make sense?

Double-Helix, BSN, RN · May 26, 2013

Behaviors: low O2 sats, nasal cannula 0.25LPM, mild subcostal retractions, coorifice breath sounds bilaterally, labs: pCO2-cap 47, HCO3 29, CO2-total 28 (all high), pt is playful and smiling, skin is pink, vitals: BP 107/54; T36.5C, P160, RR36.

Did I read this correctly? Your patient with low O2 sats (how low?) and retractions is only on 0.25 Lpm of oxygen? Might as well not be on any at all. Anyway....

My nursing dx is: impaired gas exchange r/t fluid in lungs secondary to aspiration AEB low O2 sats, retractions, lab values and bilateral coorifice breath sounds.

"Lab values" is not specific enough. Which lab values provide evidence of impaired gas exchange? In your AEB, list the specific lab values that pertain to your diagnosis.

You're missing a vital piece of information in your lab values. What's the blood pH? Without the pH, you can't determine whether your patient has partially/fully compensated respiratory acidosis or partially/fully compensated metabolic alkalosis. Based on the presentation, respiratory acidosis is most likely, but without the pH you can't prove that.

I need 4 goals, and they're suppose to be a mix of short term and long term...

Goals:

1. Pt will demonstrate improved ventilation and adequate oxygenation as evidenced by blood gas levels by discharge

Again, specifics are key. Which vital signs are you going to monitor to show that this goal has been met? What should the vital signs parameters be in order to show improved ventilation/oxygenation? What blood gas levels are you going to look at? What range should those levels be?

2. Pt will maintain clear lung fields and remain free of signs of respiratory distress by discharge

The patient doesn't have clear lung fields right now, so she cannot "maintain" clear lung fields. Likewise, the patient has s/s of respiratory distress and so she cannot "remain free" of those symptoms. Just adjust your verbiage so this goal makes sense.

3. Family will verbalize understanding of oxygen supplementation and other therapeutic interventions ( something doesn't sound right with this goal... but what do you think? and i was hoping to make this a "long term" goal... )

This goal doesn't sound right because it's very general. "Understanding of oxygen supplementation"? If someone asked me to explain that to a parent I'm really not sure I would know what to say. "Other therapeutic interventions" isn't specific or measurable. So your parents can tell you about infant massage. That's a therapeutic intervention, but is that really what you want them to know?

Let's think, specifically, about what we can teach these parents that would be of most benefit to them. Put yourself in their shoes. Their baby is in the hospital because she was having trouble breathing because she aspirated fluids. She also has a history of chronic lung issues. As a parent, what would you like to know in order to better care for your child? Think about what you can teach them in order to prevent future hospitalizations. (Here's a hint. The baby aspirated. What can you teach the parents about preventing aspiration in infants?)

You also listed some good ideas in your intervention section. Instead of making your goal about supplemental oxygen or nursing interventions, why not make it about s/s respiratory distress?

4. Pt will remain free of respiratory disease by follow up appointment

This is okay, but do you know when that follow up appointment will be? Often when we discharge a child from the hospital we give instructions to follow up with the PMD within 1-3 days. If the infant is free of respiratory disease two days after being discharged, is that really a success? Would that make it a long term goal? Instead I might suggest something like, "Patient will have _______ hospital readmissions for __________ within ______ time period" or "Patient with have _______ respiratory infections in the next ______ months."

Interventions will include
: auscultating breath sounds every 1-2 hours, monitoring client's oxygen saturation and behavior, positioning (semi-Fowler's), titrating the nasal cannula, teaching the family signs/symptoms of respiratory distress and when to call the physician, teaching the family about environmental irritants that can impair gas exchange, and supporting the family of the client with chronic illness.

For your interventions, think about what you are going to do as a nurse to help your patient achieve the goals that you have set, and list these interventions in order as related to your goals. Start by thinking about how you are going to help your patient accomplish goal #1. List those interventions. Then think about how you will help your patient meet goal #2. List those interventions, etc. Make sure you are specific whenever possible. The interventions you have now are okay, but there's a lot more that you can be doing for this patient to help her reach those goals that you have set.

KelRN215, BSN, RN · May 28, 2013

The baby came in because she aspirated. This needs to be addressed. How is she being fed right now? What do the parents need to know about feeding her when she goes home?

classicdame, MSN, EdD · May 28, 2013

I too would try to include education for parents regarding safety and prevention of recurring aspiration. Any teaching on general child safety is good

BrooklynRN11201 · May 30, 2013

agree with the above on teaching parents on safety and prevention of recurring aspiration - that should be a big one and could be more of a long term goal as it relates to discharge.

I would also consider "on day of care" as short term goals and "by discharge" as longer term goals. my clinical professors were always strict on that because you're providing daily care and can only evaluate based on shorter term goals. for instance, perhaps a short term goal is that the pt's O2 sat is at least 90% on day of care? whether that short term goal is met or not, will impact longer term goals of care.

you're also missing her O2 sat level - what' "low" for you is pretty subjective - you need an exact % or range of %s it's like saying a pt has "moderate pain" - you need to at the very least document a number the pt states based on 1-10 scale.

I wouldn't worry about ABGs or the medical dxs as much - think of only nursing dxs that will require nursing interventions. if your dx requires an intervention that requires an order from the MD, you might want to rethink it. if the ABGs show "x", then the Dr will prescribe "y" - your intervention could be "administer y as ordered" but that's a bit of a cop out - you want to focus on specific nursing dx such as assessments, teaching, etc.

firefly101 · May 30, 2013

thank you everyone for these tips! very helpful :)

Esme12, ASN, BSN, RN · May 31, 2013

Did I read this correctly? Your patient with low O2 sats (how low?) and retractions is only on 0.25 Lpm of oxygen? Might as well not be on any at all. Anyway....
"Lab values" is not specific enough. Which lab values provide evidence of impaired gas exchange? In your AEB, list the specific lab values that pertain to your diagnosis.
You're missing a vital piece of information in your lab values. What's the blood pH? Without the pH, you can't determine whether your patient has partially/fully compensated respiratory acidosis or partially/fully compensated metabolic alkalosis. Based on the presentation, respiratory acidosis is most likely, but without the pH you can't prove that.
I need 4 goals, and they're suppose to be a mix of short term and long term...
Goals:
Again, specifics are key. Which vital signs are you going to monitor to show that this goal has been met? What should the vital signs parameters be in order to show improved ventilation/oxygenation? What blood gas levels are you going to look at? What range should those levels be?
The patient doesn't have clear lung fields right now, so she cannot "maintain" clear lung fields. Likewise, the patient has s/s of respiratory distress and so she cannot "remain free" of those symptoms. Just adjust your verbiage so this goal makes sense.
This goal doesn't sound right because it's very general. "Understanding of oxygen supplementation"? If someone asked me to explain that to a parent I'm really not sure I would know what to say. "Other therapeutic interventions" isn't specific or measurable. So your parents can tell you about infant massage. That's a therapeutic intervention, but is that really what you want them to know?
Let's think, specifically, about what we can teach these parents that would be of most benefit to them. Put yourself in their shoes. Their baby is in the hospital because she was having trouble breathing because she aspirated fluids. She also has a history of chronic lung issues. As a parent, what would you like to know in order to better care for your child? Think about what you can teach them in order to prevent future hospitalizations. (Here's a hint. The baby aspirated. What can you teach the parents about preventing aspiration in infants?)
You also listed some good ideas in your intervention section. Instead of making your goal about supplemental oxygen or nursing interventions, why not make it about s/s respiratory distress?
This is okay, but do you know when that follow up appointment will be? Often when we discharge a child from the hospital we give instructions to follow up with the PMD within 1-3 days. If the infant is free of respiratory disease two days after being discharged, is that really a success? Would that make it a long term goal? Instead I might suggest something like, "Patient will have _______ hospital readmissions for __________ within ______ time period" or "Patient with have _______ respiratory infections in the next ______ months."
For your interventions, think about what you are going to do as a nurse to help your patient achieve the goals that you have set, and list these interventions in order as related to your goals. Start by thinking about how you are going to help your patient accomplish goal #1. List those interventions. Then think about how you will help your patient meet goal #2. List those interventions, etc. Make sure you are specific whenever possible. The interventions you have now are okay, but there's a lot more that you can be doing for this patient to help her reach those goals that you have set.

EXCELLENT POST!!!!!!!!!!!!!!!!!!!!!!

NicuGal, MSN, RN · May 31, 2013

What is her baseline at home? Some chronic kids always have retractions no matter what and what was the whole cap gas? What do they want her sats at? Also, if she aspirated, does she have GERD? Is she on meds, reflux precautions, does she feed by bottle or GT?

firefly101 · Jun 1, 2013

i only spent one day with this pt and unfortunately i don't have all of the information i need to make this care plan better...i am still learning what to look for and how to find it. they want her sats as high as possible i guess (without a cannula they dip to the 80s, with it they stay mid to higher 90s) she has an NJ and i actually found out this week that she may be having reflux issues but i don't know the details. i do know they increased the airflow on her cannula. she's been getting worse

NicuGal, MSN, RN · Jun 1, 2013

Her reflux must be bad if she aspirated with an NJ tube. Aspiration pneumonia is a bad thing, you have formula in there causing inflammation and then it just goes south from there,

When your primary problem is respiratory look at your gases, see if you can find out what their baseline was before. So your problem could be Impaired Gas Exchange R/T to aspiration manifested by and then list those. Interventions would include things like administer oxygen to keep sats at XX, and things like that. Your long term goal would be home with minimal/ no oxygen support ( need to know if she was on O2 at home).