Nursing Diagnoses

[believeallispossible]

I am doing a care plan on a 2 month old diagnosed with "Failure to Thrive"

My abnormal assessment findings include:

Skin-pale, dry

Color Lips-pale

Pale mucous membranes

Lack of interest in food

Abdominal pain (baby expresses by crying)

Weighs 8 lbs 3 oz for a 2 month old

loss of weight

poor muscle tone

inability to ingest food, vomits after most feedings

some constipation

exhibits hunger by crying

irritable baby

Has Hereditary Spherocytosis

ultrasound showed pt has pyloric stenosis. Surgery was performed.

Vitals are within normal range, heart-regular, lungs are clear, mucous membranes-moist

THE main problem is definately the vomiting, malnutrition, and dehydration(the abnormal lab values show this)

Here are my nursing Dx that I came up with and I would love feedback to see if I'm on the right track. I also prioritized them.

1. Imbalanced Nutrition less than body requirements r/t inability to ingest food secondary to pyloric sphincter obstruction AEB weighs 8 lbs 3 oz, loss of weight with adequate intake of (3oz q 3 hrs), vomits after most feedings.

2. Deficient Fluid Volume r/t vomiting, dehydration AEB abnormal lab values

3. Delayed Growth & Dvpt r/t failure to thrive and illness, nutritional deficiet AEB small weight for age (8lbs 3oz) in 2 months.

4. Acute Pain r/t recent surgery, dehydration, and malnutrition AEB Nausea, Vomiting, Loud Cry, Irritable

5. Risk for Infection R/F surgical wound AEB three stab sites with opsites

6. Anxiety r/t surgery and changes to the environment AEB

7. Ineffective Health Maintainence r/t inability of caregiver to judgements AEB lack of knowledge of child care by mother, and impaired support system (single mom)

8. Ineffective Coping r/t inadequate social support AEB mom & baby lives with mom's father, no family around, no family visitors besides friends, and inability to ask for help from aunt and uncle

9. Deficient Knowledge r/t lack of experience as a new mother, post-op expectations, & lifestyle changes AEB mother in late teens, 1st child.

(Also has social family issues as you can tell by some of the nursing dx; I wasn't for sure what nursing dx I could use.... Mother is unemployed, this is her 1st child, single mom, lives with father, not much family support)

I haven't done these in quite a while, so any input would be greatly appreciated. I'm pretty confident that they are okay, but I would like others feedback.

[John20]

Huh? What are you talking about?

Oh, that stuff they forced down my throat in school that I didn't see on the NCLEX or in a hospital since. Couldn't help you if I tried. Sorry about that.

[EDRN-2010]

Not sure if the link will work but you can try it...nope it didn't sorry

[PetiteOpRN]

1. Normal skin is dry, warm and intact. I would not consider pale and dry to be abnormal for a 2mo. Their skin is so thin, it can be translucent. It is also very subjective. Have your CI verify this finding so that you are sure of what you're looking at. When you are trying to assess hyration based on skin, look at turgor.

2. In this child we care about whether the mucous membranes are moist or dry.

3. A 2mo is not interested in baby food. A 2mo with PS will probably be hungry ALL the time. Baby exhibits hunger by fussing and eating, often large quantities in short periods (which is then vomited). Post-op, baby is recovering from anesthesia, and foods are given as tolerated.

4. 8lbs3oz doesn't give us the full picture. What is the percentile? What was the percentile at birth? This baby is about 5th percentile. If he was born at 5th or 10th percentile, this is not as concerning as if 50th or 75 percentile.

5. Exhibits hunger by crying is normal. So is irritability.

6. In dx#3, tell me what milestones the child has missed. Weight loss is not the same thing as developmental delay. In dx#4, do dehydration and malnutrition really cause acute pain? I would get rid of those and keep recent surgery -- that is sufficient. In dx#6, the child's anxiety is related to separation from the mother.

7. I REALLY don't like dx#7, 8, and 9. The mother sought treatment as opposed to trying to feed the baby something else. That sounds like reasonable judgment to me. The mother of a 2mo needs to know how to feed baby, change baby, safely transport baby, put baby to sleep, dress and swaddle baby, and when to take baby to the doctor. She is not expected to know the vaccination schedule or be able to do a physical assessment. What knowledge (specifically) does the mother lack? Nontraditional family is not a nursing dx. Dx should pertain to baby, not mom (#8). A mother in her late teens has just as much access to information as other 1st time mothers. This is NOT evidence for deficient knowledge.

Here are things that might be used as evidence for inadequate knowledge/lack of judgment: "mother states, 'I don't know how to take care of my baby', mother states incorrect information about baby's nutritional needs', and 'mother does x despite teaching otherwise.'"

believeallispossible, I've noticed a few posts about this patient. I'm glad that you are coming here to seek help, but I wonder why you are not going to your clinical instructor. I can give you my opinion, but it really doesn't mean that much because I've never seen the patient. Your clinical instructor should be your first resource. That is her job. I suggest that you bring your original work to her and get her input. It doesn't matter what she thinks of my work -- I'm already an RN. It is not her job to make sure I am a safe and competent care giver. It is her job to make sure you are safe and competent. I hope this post helps you gain a better understanding of normal vs. abnormal findings and nursing dx's, but it is far more important that you use your clinical instructor as a resource.

[tenexe]

Is someone actually doing a nursing care plan. I thought those were made up like lunch breaks and safe patient ratios.

[tewdles, RN]

All of my patients have nursing care plans....the delivery of my nursing care is directly related to the problem list and that is where I document changes in patient condition which affect what I do.

If my patient's have a nursing diagnosis which requires nursing action or intervention and I do not have it reflected in the POC it makes me look bad...and does not reflect the efforts of an autonomous health professional.

[CNL2B]

Is someone actually doing a nursing care plan. I thought those were made up like lunch breaks and safe patient ratios.

ROFLMAO!!! This is the funniest thing have read all day. Don't completely agree with your statement, but I get the burned out, bitter, "I had a bad day" business. We've all been there.

Our care plans are a joke -- a piece of paperwork that Joint Commission requires. They contribute absolutely nothing to the actual care of the patient.

I don't do babies so I can't contribute to the OP. Did your assignment actually require that you come up with NINE nursing diagnoses, though? That seems excessive. If I were looking at your paper, I'd try to pare it down to the most important few.