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Nursing Process Paper- pediatric "risk for" diagnosis- PLEASE HELP!

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Hello all,

I am a first year nursing student and am having quite the time with categorizing information in my nursing process paper. During class we were given a 4 year-old child's file which contained rather incomplete health history forms, physical exam forms,and health questionnaires filled out by the child's mother. The assignment is to categorize the information we gathered from the documents in a nursing process form with the headings:

Assessment, Norms/guidelines/ EBP for Assessment (also needed for planned action), Nurs.Diag., Client outcomes, Plan/Interventions, Evaluation.

I reviewed a 4.5 yr-old boy's file. In his health history form? ( can't remember for sure), "frequent otitis media with febrile seizures" was documented. Tx: "diazepam rectal gel", no mention of antibiotics or how many ear infections he has had. He has tubes in both ears and was "unable to screen" 9/07 & 10/07, but passed 4/08. Speech was documented as "understood by mother, difficult to understand by unfamiliar listener.

mother checked "yes" to engages in daily play, no reponse listed for frequency of colds

not anemic, food group servings all exceed rda's, fast food & soda rare

Last physical 11/07: height 38.75 in, 38.1 lbs BP= 80/150

The child lives with his mother & little bro., living below the federal poverty level.

My diagnosis (doesn't have to be highest priority): Risk for delayed speech and language development r/t otitis media.

Questions:

Subjective/objective data: is diet subjective? b/c mother reported and we can't measure?

Speech info- Subjective or objective?

Client Outcomes?

Plan Implementation- can I say something about needing more info?

Evaluations/Continuing Outcomes

I know this is super long, and I probably should have chosen an easier diagnosis b/c I don't relly know what I am doing yet. Could anyone shed some light on this for me? I would REALLY Appreciate any insight offered!

Thank you, Thank you! :D

ccakes

Has 7 years experience.

Hello all,

I am a first year nursing student and am having quite the time with categorizing information in my nursing process paper. During class we were given a 4 year-old child's file which contained rather incomplete health history forms, physical exam forms,and health questionnaires filled out by the child's mother. The assignment is to categorize the information we gathered from the documents in a nursing process form with the headings:

Assessment, Norms/guidelines/ EBP for Assessment (also needed for planned action), Nurs.Diag., Client outcomes, Plan/Interventions, Evaluation.

I reviewed a 4.5 yr-old boy's file. In his health history form? ( can't remember for sure), "frequent otitis media with febrile seizures" was documented. Tx: "diazepam rectal gel", no mention of antibiotics or how many ear infections he has had. He has tubes in both ears and was "unable to screen" 9/07 & 10/07, but passed 4/08. Speech was documented as "understood by mother, difficult to understand by unfamiliar listener.

mother checked "yes" to engages in daily play, no reponse listed for frequency of colds

not anemic, food group servings all exceed rda's, fast food & soda rare

Last physical 11/07: height 38.75 in, 38.1 lbs BP= 80/150

The child lives with his mother & little bro., living below the federal poverty level.

My diagnosis (doesn't have to be highest priority): Risk for delayed speech and language development r/t otitis media.

Questions:

Subjective/objective data: is diet subjective? b/c mother reported and we can't measure?

Speech info- Subjective or objective?

Client Outcomes?

Plan Implementation- can I say something about needing more info?

Evaluations/Continuing Outcomes

I know this is super long, and I probably should have chosen an easier diagnosis b/c I don't relly know what I am doing yet. Could anyone shed some light on this for me? I would REALLY Appreciate any insight offered!

Thank you, Thank you! :D

Nursing care plans suck. ;) Objective data is something that is demonstrated, so I suppose that diet could be subjective (are you in clinicals or is this a case study) I don't know if that is a NANDA approved diagnosis, do you have a care plan book? I am just a little confused since this kinda sounds like it is a case study and not a pt that you actually had. MAybe you could do something like Ineffective health maintenance r/t lack of knowledge regarding fever reduction (febrile seizures), Oh here we go R/F delayed development r/t frequent otitis media (got those from a nursing diagnosis handbook) Plan implementation are like interventions that you will be doing to help achieve your outcome. I wouldn't say need to gather more data, your teacher might agree and give you your paper back and have to make it up again.:banghead: I am in my last semester and am so glad that I do not have to do those anymore. But seriously, get you a nursing diagnosis book, saved my life in school! :)

I am in clinical at a preschool of sorts, but we were just given a child's file w/o actually meeting him/her. This assignment is frusturating on so many levels! I have a ****** minature diagnosis book that is required for the course, but that's it. Also, the child's file was so incomplete- many questions were left blank in the health history. grrr...Thank you for your help and for sharing my frustration- & I will def. get a more useful diagnosis book :)

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

your assignment is called a nursing process paper for a reason. it is because you are to follow the nursing process in reaching the nursing diagnosis, client outcomes, nursing interventions, and evaluation of the plan. it helps to review what the nursing process is and how it works with care planning. the nursing process form you were given is to help you organize all the information you were given and what you will add to it. it doesn't matter that the information that this mother gave is incomplete. care planning is about finding the patient's nursing problems and then developing strategies to do something about them. you work with the information you have. this typically happens in the real world.

if you are not a regular reader of my care plan postings, this is my suggestion of how the steps of the nursing process should be used to care plan and it should be followed in this sequence so you stay focused and on target:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

[*]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 diagnoses to use). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

[*]planning (write measurable goals/outcomes and nursing interventions)

  • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]how to write goal statements: https://allnurses.com/forums/2509305-post158.html

    [*]interventions are of four types

    • assess/monitor/evaluate/observe (to evaluate the patient's condition)
      • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.

      [*]care/perform/provide/assist (performing actual patient care)

      [*]teach/educate/instruct/supervise (educating patient or caregiver)

      [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

now, not everything in the above outline will be appropriate to do for a case scenario where you have been presented with information already. you can't do a physical assessment, for instance. but, lets work through this step-by-step in an organized fashion and see what shakes out.

step 1 assessment - you are specifically asked to separate subjective and objective data - when care planning you are specifically looking for abnormal data - i will let you fill out your form with all the data and classify it as subjective or objective - for care planning (problem solving) we are only interested in what is not normal and what the doctor has treated since that is targeted medical signs or symptoms and we're interested in that too. i want to see them in a list along with the patients medical conditions.

  • frequent otitis media with febrile seizures
    • medical treatments
      • diazepam rectal gel - i would look up the side effects of diazepam (neutropenia, respiratory depression) which puts him at risk for respiratory infections
      • tubes in both ears

    [*]speech was understood by mother, difficult to understand by unfamiliar listener

    [*]engages in daily play

    [*]living below the federal poverty level

    [*]bp= 80/150 - is this correct or a typo? this is a very high b/p for a 4.5 year old child. this is a high b/p for an adult. this is a b/p that is critically high, especially the diastolic!

step #2 determination of the patient's problem(s)/nursing diagnosis - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

  • if there is, indeed, a critical hypertension issue going on, the diagnosis would be decreased cardiac output r/t altered contractility aeb b/p of 80/150
  • impaired verbal communication r/t learning deficit aeb speech that is difficult for others except the mother to understand.
    • this child has probably not learned to speak correctly because of his many early childhood ear infections which caused temporary interference with his hearing. if you read about how children learn language, hearing is a necessary part of that cycle which was impaired during this child's early years. children learn to speak by hearing others. deaf people do not talk like others because they have never heard others actually speak so they have no reference to mimic and something similar is probably what is happening with this child as well.
    • http://www.merck.com/mmpe/sec19/ch299/ch299a.html

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my diagnosis (doesn't have to be highest priority): risk for delayed speech and language development r/t otitis media.

while it is a risk, the problem actually already exists and can be covered in the diagnosis of
impaired verbal communication.

subjective/objective data: is diet subjective? b/c mother reported and we can't measure?

what are your guidelines for classifying data as being subjective or objective? it doesn't matter that
you
can't measure it. what the mother reports is
objective
data.

speech info- subjective or objective?

again, everything the mother reports is
objective
data.

client outcomes?

see #3 in the outline above (which, by the way, you should print out). outcomes are the predicted results you expect to happen once your interventions are carried out.

plan implementation- can i say something about needing more info?

yes. see #3 in the outline above again. there are 4 kinds of nursing interventions. one type is to assess/monitor/evaluate/observe which is a
professional
way of saying "get more information".

evaluations/continuing outcomes

when you evaluate, you are going back and essentially re-assessing to see if the same signs and symptoms that led you to diagnose the problem (nursing diagnosis) are still present and/or present to what degree. did the interventions you ordered work, or are they not working (are the goals/outcomes being achieved)? this is the time to make adjustments to any of the pieces and parts of the planning. you can tweak or change the interventions or goals/outcomes. all of these are intimately related to each other. the
link that binds them is the abnormal data that supports the existence of this problem
. occasionally a problem can be nipped in the bud by actually curing/obliterating the underlying cause of the problem, but that doesn't happen as often.

hope that helps.

Daytonight,

Thank you, Thank you, Thank you!!! I was definetly in over my head. The few case studies I have done before, as well as those offered in my course textbooks, have been very straight forward and never involved medical records as in this case study. I spent so much time researching this and because of it, am late turning the assignment in. My peers all did less involved diagnosis like "imbalanced nutrition..." or others offered as examples in our book. Like so many children in need, this boy has many interrelated, serious issues that seemed to be brushed aside- I wanted to try and help. Thank you so much for helping me with this- you are truely amazing!

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

Please tell me the B/P was just a typo. When I saw that I almost fell off my chair over here. I didn't think it was related to the diazepam, but I doubled checked just to make sure. It's like it is just sitting there out of the blue with no other clues or symptoms to relate it to. If it is really a true symptom, the more I think about this, the little boy is a Risk for Injury (stroke).

Don't worry! It was a typo. I'm sorry to have caused you any stress. Thanks again for your help!:)

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