Well Child Check up Nsg DX!!!

  1. AhhhGGGG! I need to come up with a nsg dx for my pt. but am completely stumped on what to use, and to make the matter worse my teacher is known for going postal.. ripped my friends up in front of her saying that she should have known better than to use the one in the book and using a non-nanda would have been better (r/t jaundice baby)
    Anyhoo.. here is my problem. THE KID WAS WELL.. uh.. no problems... happy healthy perfectly formed 2 month old boy who was in the 60% or higher for everything and had all of his immunizations. He was there for his 2month shots and well baby. Mom is a nurse so she isn't really deficient in knowledge, you know?? any ideas?? i have to have interventions too.. but if I get the dx I can come up with those.
    any help making my light bulb ding would be great!!! Thanks!
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    About dani_girl

    Joined: Sep '06; Posts: 124; Likes: 63


  3. by   donsterRN
    How about a "risk for" diagnosis?
  4. by   dani_girl
    Like risk for suffication? Risk for injury?

    Thanks for the thought! By the way my careplan books don't have any info on them what are the "disorganized infant behavior?" DX what does that mean??
  5. by   Daytonite
    How can you have interventions for symptoms/problems that do not exist since you say this is a well-baby and there is nothing wrong? Interventions are based upon problems or needs of the patient that are determined by the assessment. What are these interventions? If you can make your own diagnosis then make this one: Effective Health Management. All I would do, then, is look at the related factors and defining characteristics of Ineffective Health Management and flip them around to make them into positive criteria and then use the ones that would apply to your patient. Instead of patient symptoms/problems, you'll have needs because the child is "normal". That sounds like a logical assumption to me. There's also a Delayed Growth and Development diagnosis that you could pull the same trick with and turn into (whatever the opposite of delayed is) Growth and Development. Then, as long as you follow the PES (Problem, or Nursing diagnosis-Etiology, or related factor-Symptoms, or defining characteristics, in this case needs) format of constructing your nursing diagnostic statement and using your symptoms as the reason for your interventions and outcomes, you should be good to go on this. Surely, she can't fault you if you are following the nursing process in putting this together.
  6. by   dani_girl
    Thanks you guys!
    Daytonite I know what your saying about interventions.. but it is the assignment.. she can be pretty brutal.. but even if it was a Risk for (like say Aspiration) I can make my interventions like assessing cough and gag reflex , or maintain upright position for 30 to 45 minutes after feeding these are not for my infant but you get the idea..
    My school really likes interventions... alot
    But I think the Effective Health management will be great. I appreciate the help!!
  7. by   Daytonite
    in my bsn program 20+ years ago we had to make up our own diagnoses.

    keep in mind that when you are using a "risk for" diagnosis, you are writing a diagnostic statement with the aeb items that are invisible. you are still addressing them except these are symptoms that haven't occurred so you are basically left to monitor for them or do things to prevent them from happening. for example if you say risk for aspiration r/t immature gag reflex the aeb part is still something you consider but never stated on paper. risk for aspiration r/t depressed gag reflex aeb choking, coughing, cyanosis. your interventions are targeted at the prevention of the symptoms (choking, coughing and cyanosis). make sense?
  8. by   dani_girl
    exactly. That's is how we do it too. Thanks for your help!
  9. by   nskoog
    What about a Wellness Dx?

    Readiness for enhanced Immunization status is one that might work.. AEB Obtaining immunizations recommended for age, etc.

    It's definition: A pattern of conforming to local, national, and/or international standards of immunizations to prevent infectious disease(s)...
  10. by   santhony44
    You say mom is a nurse so not deficient in knowlege. Well, I think that might still be a possible diagnosis. I can tell you that it's different when it's your own kid. In this situation, she is primarily Mom and not Nurse.

    This is particularly true if she's not in pediatrics. If she's, say, a CCU nurse, then she may not remember much about things like immunizations, since she doesn't deal with those on a regular basis.

    So, something that would require you to assess her knowledge level would be appropriate here. In fact, she might very much appreciate someone taking the time to be sure that she is given the information she needs and that you don't just assume she knows it all.

    I was, in fact, a PICU nurse when my younger son got very sick at 6 months of age. I just knew something was wrong- I was in Mommy Mode. Only retrospectively could I put the clinical picture together.
    (He's a very healthy 17-year-old now.)

    Don't discount Knowledge Deficit with just about any patient/parent, but particularly not with one who works in health care.