Need Pedi Critical Careplan Help!

Jolie, BSN · Mar 30, 2007

First of all, are you sure that his diagnosis isn't persistant pulmonary hypertension (PPH)? Primary hypertension in a newborn is virtually unheard of. Do you know his gestational age, birth weight or current weight?

If you go back and review fetal circulation, you will find that during fetal life, the pattern of circulation through the body differs greatly than the pattern of circulation after birth. At the moment of birth, when the cord is clamped, the newborn undergoes a transition in circulatory patterns and oxygen delivery (the oxygen is now coming from the lungs, not the placenta), and a major change in blood pressure (from high pulmonary pressure and lower systemic pressure to low pulmonary pressure and higher systemic pressure), as well as the functional closure of the ductus arteriosus. If these changes do not occur smoothly (due to sepsis, pneumonia, respiratory distress syndrome, meconium aspiration or asphyxia), the baby may develop persistent pulmonary hypertension. This results in insufficient blood flow to the lungs, and lack of oxygenation to the entire body. This is a dire, life-threatening condition.

Treatment consists of intubation, mechanical ventilation (with the baby paralyzed and heavily sedated), and drugs to lower pulmonary blood pressure, as well as to treat the underlying condition, such as antibiotics and/or surfactant The ventilator settings are usually manipulated to induce respiratory alkalosis, which can help to dilate the pulmonary blood vessels, hopefully lowering pulmonary blood pressure and improving lung perfusion. If this treatment method is unseccessful, high-frequency ventilation or ECMO may be necessary.

Ineffective breathing pattern and impaired gas exchange would be appropriate nursing diagnoses. Unless this child is a preemie (babies with PPH are usually full term, or nearly full term), I don't think that immature lung development applies to this case. "Upper lobe atelectatic densities" sounds like pneumonia to me, probably due to infection or aspiration, either of which might explain his PPH. His low WBCs also support the nursing diagnisis of infection (actual or potential). Did his mom have any risk for infection such as (+) Group B strep or prolonged rupture of membranes?

His full-body edema is a side-effect of his paralyzing and sedating medications as well as immobility. Fluid volume excess sounds like a good choice for this one. You might want to consider impaired tissue perfusion as a nursing diagnosis, supported by his altered blood pressure, heart murmur (due to a patent ductus arteriosus which should have closed at birth), and impaired circulation to his extremities which are likely cool to the touch and probably have diminished capillary refill.

His elevated blood sugar can be attributed to stress. Altered nutrition, less than body requirements due to inability to feed orally is an important consideration. I assume he is receiving TPN and lipids via a PICC or central line, as nutrition is vital to his ability to recover.

As for prioritizing, always do Airway, Breathing and Circulation first. Then move on to pain, infection, nutrition, social.

You're right. You've got a complex patient. It sounds like you are off to a good start. Please let us know how he is doing after your clinical day. Most babies with PPHN begin to turn the corner at about a week of age, so hopefully things will soon look up for this little guy.

Daytonite, BSN, RN · Mar 30, 2007

it sounds like a big part of your problem here is not knowing enough about the pathophysiology of the patient's medical problems or what the various lab tests are indicating. time to hit the books and other references to find this information. here's some weblinks that you may find helpful.

http://www.emedicine.com/ped/contents.htm - list of pediatric disease articles on e-medicine. each article will include a discussion of the pathophysiology of the disease process being discussed, signs and symptoms as well as current medical treatment.

http://www.emedicine.com/ped/topic1747.htm - patent ductus arteriosis

http://www.emedicine.com/ped/topic2530.htm - pulmonary hypertension, persistent-newborn

http://www.emedicine.com/ped/topic1097.htm - hypertension

http://www.emedicine.com/ped/topic2531.htm - idiopathic pulmonary hypertension

http://www.emedicine.com/ped/topic2778.htm - neonatal hypertension

http://www.emedicine.com/ped/topic70.htm - respiratory alkalosis

medicine net diseases & conditions a to z index http://www.medicinenet.com/diseases_and_conditions/article.htm

web md index list of medical conditions http://www.webmd.com/a_to_z_guide/health_topics.htm

family practice notebook (use search box) http://www.fpnotebook.com/index.htm

medicine net procedures & tests a to z index http://www.medicinenet.com/procedures_and_tests/article.htm

web md index list of tests http://www.webmd.com/a_to_z_guide/medical_tests.htm

lab tests online http://www.labtestsonline.org/

armed with that information you take your list of abnormal data, examine the definitions, defining characteristics and related factors of some nursing diagnoses that look like they might be appropriate and start assigning them. (i know i told you this before in other posts.) i recently noticed that the appendix of my taber's cyclopedic medical dictionary had a nice classification of the nanda diagnoses into categories by gordon's functional health patterns and by doenges & moorhouse's diagnostic divisions which will help you find diagnoses by body system problems or needs if you are not familiar with all the 100+ nursing diagnosis titles. you can use the same symptoms in more than one nursing diagnosis

i almost had a heart attack when i saw you write:

it wasn't asked for on my careplan paperwork

because it tells me that the process of data assessment and collection is still not clearly being understood. just because specific data wasn't asked for on a piece of paper that you are taking into your clinical area with you doesn't mean that you skip looking for it. take another blank piece of paper with you next time and go through your patient's chart like you are looking for a needle in a haystack. take down all kinds of information, whether it's asked for on your clinical worksheet or not. you can sort it all out later at home. once you are away from the clinical area you can't get to that information anymore unless you've made an effort to copy it down. at a minimum you should be copying down signs and symptoms as well as the medical diagnoses from the physician's history and physical exam, the reports of any consulting physicians, information from the doctor's progress notes, the diagnostic results of x-rays, lab tests, pathology and any cultures, significant notes made on physical therapy, respiratory therapy and dietary notes and information from the nursing admission assessment and the medication sheets and kardex.

discobunni · Mar 31, 2007

Jolie you were right it was PPH... I misunderstood and was looking in all the wrong places to try and understand it. Everything you listed fits to a "T" and I remember it said PPH, I don't know where I got primary. That is one thing that discourages me is that I don't get to collect info first before seeing my pt. I go to my clinical day and get the info then, so I do my research and such after the fact....

Thank you for all of the links Daytonite. I thought there were spaces for me to write down ABG's on my paperwork and I thought I had written all my information down and then realized that I hadn't, and only had the pH from memory. I'll definitely learn from my mistake this time. One thing I really hate is the writing in the chart is so small and completely illegible by doctors, nurses and the rest of the medical staff. UGH That makes it terribly frustrating trying to figure out the rest of it...because it is like that information is not there :angryfire just venting. Thank you both so very much for your responses.... they are greatly appreciated and have helped me tremendously!

Daytonite, BSN, RN · Mar 31, 2007

When you start working at a regular job and deal with the same doctors on a regular basis you actually start to be able to recognize their chicken scrawl. The reason is because they tend to order the same stuff again and again. Nothing is more rewarding than being able to walk up to someone who is trying to decipher some doctor's scribbling and quickly rattle off exactly what that scribble says! Wait! You'll be able to do it, too, some day.