Pediatric Care Plan Diagnoses

[boo439981]

Hello. Just wanted to say how much I appreciate everyone on this site and all the help they have given to us fledging nurses.

I was hoping you could help me once again. I am curently in my pediatric clinical at a LTC facility. My patient is a 7Y male with the following dx:

MR/DD, spastic -athetoid quadriplegic Cerebral Palsy with remote seizures, tracheostomy, chronic lung disease-asthma, Gastrostomy.

Vitals were within range except for respiration -26bpm. Adventitious breath sounds in all fields: coorifice rales noted in the upper quadrants, rhonchi, and slight wheezing upon expiration. Pulse ox was 97%. Did not appear to have difficulty breathing, however had an ineffective cough and needed several trach suctions during shift to remove thick secretions. After suctioning, pulse ox went to 99% and less coorifice rales were heard.

Due to his quadriplegic CP, he is either chair or bed bound. Movement is limited to some gross motor movements with arms to when reaching desired object or to remove an undesired one. Fine motor skills are lacking.

He is on a continuous tube feed at night and intermittent during day, which he tolerates well. The PEG site is intact and clean.

These are the diagnoses (I need 3 for care plan) I thought are most important for my patient in regards to my assessment:

1) Ineffective Airway Clearance r/t inability to effectively cough up secretions aeb coorifice rales in upper lung fields and elevated respiratory rate.

2)Impaired Physical Mobility Level IV r/t to neuromuscular impairment aeb inabilty to voluntarily change position and perform fine motor skills.

3) Risk for Aspiration r/t presence of tracheostomy and gastrostomy aeb continuous tube feeding at night while in a supine position.

THank you for taking the time to help me. Any advice is appreciated.

[Esme12, ASN, BSN, RN]

:)...well done

[CoolKidsRN]

The above nursing dx looks good to me as well! Keep up the good work.

[boo439981]

Thank you both so much for taking the time to read my post.

[Esme12, ASN, BSN, RN]

It does my heart good to see the growth of the students.

[Girlafraid13]

I'm not too sure about risk for aspiration rt presence of trach/gtube aeb.....

From my understanding a risk for diagnosis doesn't contain an "aeb" because it's a potential risk with no "evidence"

[Girlafraid13]

For example: risk for aspiration r/t continuous gtube feeding. And then your nursing intervention can be: keep pt upright during feeding, keep pt upright at least 30 mins pc

[Esme12, ASN, BSN, RN]

For example: risk for aspiration r/t continuous gtube feeding. And then your nursing intervention can be: keep pt upright during feeding, keep pt upright at least 30 mins pc

that is much better....I agree.

[boo439981]

Ahh, good point. Yes, I agree that makes more sense. Thanks for the great advice!