step 1 assessment - collect as much data as you can about the patient's medical condition and treatment, its pathophysiology, signs and symptoms, possible complications; include your own physical assessment of the patient, and assessment of their ability to perform adl's; you are looking for all abnormal data
step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data
- periorbital cellulitis of right eye
- had a cold and headache for 4 days with a fever
- had a picc line inserted in the l ac for home care antibiotics
- don't forget to include the symptoms of the periorbital cellulitis (i don't see any listed), any visual disturbances, signs and symptoms of the cold that may still be remaining (is she still coughing and have congested lungs? does she still have a headache?). since she is 15 years old she is still a child and that affects the way she views the world and how we deal with her, so her developmental stage is important to determine and incorporate into your assessment. look at erickson's developmental stages since she will most likely fit under either the adolescent stage (identity vs. role confusion) where the child is under role model and peer pressure to try many different roles (good patient?) to integrate them into their self-image of themselves. could that account for some of her anxiety?
step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use
- 15 year old female
- extremely anxious about the picc line
- sed rate 76 high -what does this mean?
- crp 2.0 high what does this mean?
- gluc 144 high - why is this elevated if she in not diabetic?
- alk phos 175 high - this level is usually elevated in 15 year olds because of the increased bone growth
- lymph, absolute 1.3 low - what does this mean?
- monocyte, % 18.9 high - what does this mean?
- after you get more abnormal symptoms on your list, then begin looking for diagnoses to go with them.
anxiety r/t picc line insertion
risk for infection r/t picc line insertion. i didnt know if i could you risk for infection because she already has an infection.
anxiety is a very broad term and requires explanation. did you talk with her? what kind of things was she telling you that led you to make a judgment that she was anxious? i would look at her level of development and where she needs to be as a 15-year old first. her anxiety may be a symptom of that rather than a problem in and of itself. if she is in the normal adolescent stage of identity vs. role confusion part of her anxiety (no symptoms of which you listed) would be connected with how she is expected to perform her role as a patient in caring for this picc line. that's a big responsibility for a 15-year old. (i've had a picc line for 6 months and i know what home care is involved with it.) rather than anxiety as being the major problem here i would suspect that ineffective role performance
(related factors for this diagnosis that fit with this patient might include body image alteration, low self-esteem, developmental level, school demands, young age, and/or lack of knowledge) is more likely and in keeping with her developmental level. as a teenager there may also be some disturbed body image
going on (related factors for this diagnosis that fit with this patient might include perceptions of disfigurement, fear of rejection by others, being seen by peers as being different from everyone else), but i don't know since there wasn't any data posted in regard to this. there may also just be deficient knowledge, picc care r/t lack of knowledge
that is needed.
when the diagnosis of anxiety
is used its related factor must be a threat, change or crisis that causes an anticipation of danger. since the picc line has already been done "picc line insertion
" as the related factor doesn't make sense. it would if the insertion was going to happen in the next few days, but it has already occurred. so, what is she afraid of now? that makes me think that there are other things she is worried about
: the care of the picc line, how the picc line will look to others--and there are other diagnoses as i mentioned just above for those.
it is appropriate to use this. the infection being avoided is sepsis which, at this point, she does not have. strict aseptic technique is used for all dressing changes of the picc line to avoid introducing bacteria into the wound. the tip of the picc line is in the vena cava of the heart. the last place you want bacteria to migrate is along this picc line to the vena cava where they can be dropped directly into the bloodstream and carried to any organ. sepsis:
the spread of an infection from its initial site to the bloodstream initiating a response that adversely affects blood flow to vital organs.
interventions for this nursing diagnosis is limited to:
- strategies to prevent the problem from happening in the first place
- monitoring for the specific signs and symptoms of sepsis
- reporting any symptoms that do occur to the doctor or other concerned professional