Nursing Care Plan - need assistance

Daytonite, BSN, RN · Jun 21, 2009

nursing diagnosis: impaired gas exchange related to low rbc count as evidenced by pallor on the face and fingers, and dyspnea.

this diagnosis is used when the patient has a respiratory problem and something is medically wrong with the lungs. that doesn't sound like what is happening here. the related factor (

low rbc count

) must be what is causing the nursing problem which you are diagnosing as

impaired gas exchange

which is defined as

excess or deficit in oxygenation and/or carbon dioxide elimination

at the alveolar-capillary membrane

(pg. 112, nanda international nursing diagnoses:

definitions and classifications 2009-2011

). a

low rbc count

is not how an

excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane

occurs. you have to look at the baby's medical diagnosis for the reason why the alveoli of their lungs are filled with mucus or other debris which interfere with the exchanges of the oxygen and the carbon dioxide gasses. if the problem of inadequate oxygenation is because of a medical diagnosis of anemia but the lung alveoli are clear to auscultation then you have diagnosed this nursing problem incorrectly.

although the baby's rbc count is low are these hemoglobin (68 gm/l) and hematocrit (0.23%) levels high? [american labs measure hgb as grams/

dl

and hct in whole numbers percentages.] if so, then

deficient fluid volume

is the problem and not

impaired gas exchange.

other symptoms of anemia are fatigue, weakness, headache, sore tongue, drowsiness, malaise, and gi disturbances. some of these may be the origin of the baby's irritability since a baby cannot speak and tell us what problems they are having. the baby's symptoms need to be broken down, listed out and other nursing problems considered.

regarding your nursing interventions. . .interventions must address the objective and subjective cues (signs and symptoms, or evidence) that support the existence of the nursing problem which you give as pallor on the face and fingers, and dyspnea. several of your interventions or their rationales made no sense:

monitor vital signs, note for changes in cardiac rhythm (rationale: hypoxia is associated with signs of increased breathing effort.) ???
- this is an intervention that sounds more like it belongs with a nursing diagnosis of activity intolerance
[*]administer meds as indicated:- ferlin i ml bid-folic acid 5 mg i tab bid-fortum 270 mg iv q2h nst (rationale: drug therapy helps to increase haemoglobin levels and promote maximum potential of wellness) - i could not tell from this care plan if hemoglobin levels were elevated or decreased. it is never brought up.
- why the iron and folic acid? is there a dietary deficiency of iron and folic acid in this baby's diet? is that the real nursing problem here: imbalanced nutrition: less than body requirements related to lack of ingestion of iron and folic acid as evidenced by . . .
[*]and these two interventions are opposite to each other and were confusing to me:
- recommend quiet atmosphere and bed rest if indicated (rationale: this enhances rest to lower body’s oxygen requirements and reduces strain on the heart and lungs.)
- recommend mother to stimulate the baby to cry once in a while (rationale: enhances lung expansion to maximize oxygenation for cellular uptake.)

regarding goals. . .our goals must be nursing oriented. your goals are:

display laboratory values within acceptable range
- what are the acceptable ranges? i was using mosby's diagnostic and laboratory test reference to check the hemoglobin and hematocrit levels that you had listed on your care plan. never assume that the people reading your care plan know what you are talking about. i'm in america. where are you? i figured out pretty quickly that you probably weren't in america.
[*]manifest glow on the face and return of color on the fingers
- what is a "glow"? how do we scientifically describe "color on the fingers"?

for your evaluation of the goals you wrote. . .goals partially met as evidenced by:

increase hemoglobin level after blood transfusion
return of pinkish color on both hands and face.

the hemoglobin level elevated as a result of a medical intervention not because of any nursing intervention that you ordered. you need to evaluate whether or not the patient was able to "display laboratory values within acceptable range" based upon the nursing interventions that you ordered in this nursing care plan. in other words, did you plan work? that is what you are evaluating. i looked pretty closely at your nursing interventions. there were no independent nursing intervention that even talked about how to go about elevating the rbc count. it was all because of the doctor's orders. if giving a blood transfusion, iron and folic acid did it, what was the nursing part in all of this?

again, i have to point out that impaired gas exchange is about the excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane and addresses the respiratory system. i do not believe you have diagnosed this patient's problem correctly. this really sounds more like a problem of deficient fluid volume especially if the patient had to receive a blood transfusion.

stormbeige · Jun 22, 2009

Hello,

Thanks for criticizing my work. I really learned a lot and have revised my nursing care plan.

I have made a new nursing diagnosis for the same patient.

Imbalanced nutrition: less than body requirements related to inability to ingest food because of presence of cleft palate as evidenced by low Hgb, Hct and low RBC count. Is that right?

I have also made a draft of my new nursing care plan. Hope you can view and criticize it. Thanks a lot.

http://www.scribd.com/doc/16645060/NCPImbalanced-Nutrition-Needs-to-Be-Criticized

stormbeige · Jun 22, 2009

I am sorry, I have given you the wrong link. Please disregard it.

Below is the correct link to my new nursing care plan draft. Kindly check it. Thanks!

http://www.scribd.com/doc/16646436/NCPImbalanced-Nutrition-Not-Revised

Daytonite, BSN, RN · Jun 22, 2009

nursing diagnosis: imbalanced nutrition: less than body requirements related to inability to ingest food because of presence of cleft palate as evidenced by low hgb and hct and inadequate formation of rbc.

i would word the "related to" part this way:

related to inability to ingest food secondary to cleft palate

because

cleft palate

is a medical determination made by a physician.

inadequate formation of rbc

suggests that there is something wrong with the way the body makes the rbcs. is that correct? what does that have to do with the baby's nutrition? that doesn't make any sense to me. when someone doesn't ingest enough food they lose weight and probably get dehydrated. don't you have a weight on this baby that shows he is below his weight for his age? is he dehydrated? does he have symptoms of dehydration: dry mucous membranes, poor skin turgor, decreased pulse volume, decreased blood pressure, thirst, decreased urine output, darkly colored concentrated urine, a fever?

the nursing diagnostic statement can broken down into these components:

problem:

imbalanced nutrition: less than body requirements

etiology:

inability to ingest food secondary to cleft palate

symptoms:

low hgb and hct and inadequate formation of rbc

the nursing interventions are aimed at and treat the symptoms. the definition of this diagnosis is

intake of nutrients insufficient to meet metabolic needs

(page 74,

nanda international nursing diagnoses: definitions and classifications 2009-2011

). so, based on your diagnostic statement your interventions should be treating the

low hgb and hct and inadequate formation of rbc.

i do not see how any of these except for the last 3 are doing anything for the low hgb or hct or rbc problem.

keep strict documentation of intake (count # of milk bottles consumed), output (count/weigh diapers), and calorie count (rationale: this information is necessary to make an accurate nutritional assessment.)
explain the importance of adequate nutrition and fluid intake to the mother/caregiver (rationale: the mother/caregiver may have inadequate or inaccurate knowledge regarding the proper of feeding of a baby with the said disability)
instruct the mother/caregiver to feed the infant gently using a commercial cleft lip nipple (rationale: this will facilitate sucking and will make feeding easier for the baby)
instruct the mother/caregiver that when feeding the infant,, place the infant in a 90-degree position with the head slightly flexed. (rationale: this position will improve swallowing ability of the infant)
monitor laboratory values, and report significant changes to physician. (rationale: laboratory values provide objective data regarding nutritional status)
administer meds as indicated:- ferlin i ml bid-folic acid 5 mg i tab bid-fortum 270 mg iv q2h nst (rationale: this drug therapy will help in the adequate formation of rbcs)
administer blood transfusion as prescribed (rationale: this will treat the decreased level of both hemoglobin and hematocrit)

short term goal is to

gain 2 lbs per week
- the problem i have with this is that nowhere in your assessment data is the child's weight mentioned or compared to normal values. you cannot talk about a goal of the child gaining weight when you have no baseline weight for the child that establishes that they are below a normal weight range. then, your interventions go on about feeding the child when nowhere in your assessment data is there anything pertaining to problems with how the child feeds. the interventions sound nice, but you have provided no reason for them to be there.

long term goal is to

exhibit no signs or symptoms of malnutrition by time of discharge from treatment (e.g., electrolytes and blood counts will be within normal limits; a steady weight gain will be demonstrated; patient will exhibit increased energy)
- nowhere in your assessment data is there any evidence of the signs of malnutrition. if you began with signs and symptoms of malnutrition, then it is logical that you should have nursing interventions to treat malnutrition and then this long term goal would make sense.

a nursing care plan is a very logical piece of problem solving. we determine the problem which consists of component signs and symptoms. we treat those signs and symptoms with nursing interventions (independent and collaborative). goals are the predicted results of both our independent and collaborative nursing interventions. when we evaluate the care plan we are evaluating if we met our goals and revise them and/or nursing interventions as needed for the very simple purpose of working toward solving the problem. everything is based upon the signs and symptoms that determine the problem that the patient has. until you establish what this patient's signs and symptoms are that you are going to call imbalanced nutrition: less than body requirements you will have to keep revising this care plan.