Hey guys! So I was wondering if anyone can help me with nursing diagnosis for my 2 month old patient who recently had a VSD closure & PFO closure. The whole day she was crying non stop at times, would always spit up, she sounded like she needed some suctioning in her oropharynx? Lungs were clear. My not so helpful nurse was saying how it may be due to the side effects of being intubated? Something inflamed? She has a hard time eating from a bottle doesn't want to bc she spits up too so she has an NG tube. She has history of VSD,ASD & CHF.
Im trying to formulate a nursing diagnosis that's measurable..(needed for care plan) bc I wanted to use some altered feeding pattern, or for her having spit up or something bc I'd say ineffective airway clearance but Spo2 is 100% & lungs are clear. Any help?
Jul 14, '17
I'm curious about "your" not so helpful nurse? It's not her job to help you with your homework -- only to allow you to participate in her pt's care. She did provide you with some education which is not her job either, nor is she getting paid extra for your presence -- it's your clinical instructor's job, and s/he IS paid to teach you.
Anyway, yes the ET tube can irritate the trachea, which is why any intubated/trached pts can have mucus even if no infection. Or it could be gastric...I didn't catch how long she's had the NG.
Ineffective feeding pattern is an appropriate dx... but why is she crying all day? What are some things that cause children to cry...especially postop children?
How is her cardiac assessment?
Jul 15, '17
I meant she wasn't helpful when I tried asking questions to clarify more about the patients we had. I understand it isn't her job to do those things but she definitely wasn't in the mood to guide me that day when I simply wanted to learn. Sorry if us student are annoying but you guys were once too... but..It was my first day on the unit & we only get to be there four times. I was trying to figure out how to learn without being such a bother but guess it didn't work out.
I've got it all figured out thanks for responding your feedback.