Peds care plan help

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I am working on my care plan for peds and am quite confused. We have to do 2 care plans on our patient; 1 physical and 1 psychosocial.

My patient was a 14 month old girl who had a G-tube inserted the afternoon before I got her. She was receiving tube feedings Q4 and tylenol for pain. Her development and cognitive level was that of a 3-4 month old. She was failure to thrive with cerebral palsy and hx of GER. Her weight was 75th percentile at birth and well below the 3rd percentile now.

Ok, so my first Nanda thought was impaired nutrition: less than, but there are really no NOC's that I like for this patient. Her FTT is dependent on the CP. So, in this case can I go with Pain, Acute for the Nanda?

Then for the psychosocial plan, since she is functioning at a 3-4 month old level, she doesn't experience the fear of the strange experience as she would if she were functioning at her chronological age level. However, she does cry when strangers approach her crib. So, would Fear be appropriate, or is there something else that would fit better?

I appreciate any insite :wink2:

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Specializes in Telemetry.

If I was doing this care plan, these are some of the things I would think about. These are just thoughts. I don't know if they are NOC or NANDA (or whatever your school requires) though.

Acute pain r/t recent surgery (placement of G-tube) AEB things like altered vital signs, facial grimacing, etc.

Impaired mobility r/t CP

Impaired skin integrity r/t prolonged immobility

For psychosocial, maybe you could use knowledge deficit r/t new placement of G-tube AEB mom states "will I give meds through this tube"... etc.

I guess you could do fear r/t ... AEB baby screams every time I approach the crib.

Those are the first that come to thought. Think ABC's first. Does she have impaired circulation? Look in your book on CP & a lot of books will have a section w/ the nursing process for the specific dx. Good luck.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

care planning is problem solving. it is based on using the nursing process as a problem solving tool in accomplishing this. we use assessment as our fact finding activity. we need facts (evidence) to support the problems that we diagnose. think of yourself as a kind of detective. without finding the evidence to support the nursing problems, you can't diagnose them. intuitively, you know they exist (pain, impaired nutrition), but you can't quite figure out how to get to them. let me show you how using the nursing process.

the nursing process consists of 5 steps: assessment, problem identification (nursing diagnosis), planning, implementation, and evaluation.

step 1 assessment - the collection of data. assessment consists of:

  • a health history (review of systems) - cerebral palsy, hx of ger, failure to thrive, weight was 75th percentile at birth
  • performing a physical exam - development and cognitive level is that of a 3-4 month old, weight is well below the 3rd percentile now, cries when strangers approach her crib - what else? did you measure her responses against those of what a normal 3-4 month old child should do? she's in erickson's trust vs. mistrust stage. how does she fit in with it, or not? is crying when someone approaches her normal for that stage? she has a g-tube. . .how does the site look. . .does it need care? does she try to pull at it? describe her pain. where is her pain? how can you assess its intensity? how will you know when she is in pain to even medicate her? how will you communicate with her--communication is a psychosocial issue.

    [*]assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) this is a 14 month old child. . .who takes care of her adls because a 14 month old can't walk, cook or wash clothes. she is dependent on an adult for all care: bathing, dressing, eating, toileting and mobility.

    [*]reviewing the pathophysiology, signs and symptoms and complications of their medical condition - look up cerebral palsy, failure to thrive and ger(d) so you know what these conditions are. learn about their signs and symptoms and think back to whether or not your little patient actually had any of those symptoms. this is how you learn to improve your assessment techniques for future patient contacts. you also need to know the pathophysiology of these conditions in order to choose nursing diagnoses and understand what etiologies (related factors) you will need to go with them when you compose your diagnostic statements. the big burning question in my mind is how did this kid get into a failure to thrive situation in the first place? what's the history on that and what is the parental involvement with it because the parents are the ones responsible for feeding this baby?

    [*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered

step #2 determination of the patient's problem(s)/nursing diagnosis - to make a diagnosis we must have done assessment in order to obtain as much data as possible. we need signs and symptoms. all diagnoses are based upon a collection of signs and symptoms. this is why your diagnostic statement consists of a problem (the nursing diagnosis), its etiology (the cause of the problem) and the evidence of the problem (signs and symptoms). it is all very logical. what makes it a tad frustrating when we are new at doing this is we can't use medical diagnoses and must re-word them into generic medical terminology. nanda calls it nursing language. if you use nanda taxonomy to write your nursing diagnoses you don't have to think as hard. the taxonomy actually has a lot of the related factors and signs and symptoms for all the nursing diagnoses already listed out. the difference between medical diagnoses and nursing diagnoses is that medical diagnoses are much more precise. there is no room for error in the diagnosing of something like pneumonia. nursing diagnoses, however, are more lax. while there is no doubt that deficient fluid volume is about dehydration, the patient doesn't have to have all the defining characteristics and there is a lot of leeway as to someone having deficient fluid volume or not. what i am saying is that there are a lot of shades of gray. it is because with nursing diagnoses we are dealing with patient's responses to medical conditions or their environment. a lot of the signs and symptoms are behavioral so they fluctuate.

ok, so the data that you did post is what needs to be paired with nursing diagnoses

  • development and cognitive level is that of a 3-4 month old
  • weight is well below the 3rd percentile
  • cries when strangers approach her crib - i believe this is a normal trust vs, mistrust response

i have a copy of a taxonomy. i would not say the imbalanced nutrition: less than body requirements is a problem now because the gastric tube is in place. unless you have lab evidence of nutrition problems, the patient's feeding needs are now being met.

  • delayed growth and development r/t nutritional deficit aeb development and cognitive level is that of a 3-4 month old and weight is well below the 3rd percentile
  • i cannot diagnose acute pain because there are no symptoms for it.
  • risk for impaired verbal communication r/t impaired ability to articulate secondary to cerebral palsy

step #3 planning (write measurable goals/outcomes and nursing interventions) - for each nursing diagnosis addressing each symptom that supports the diagnosis. you can also, in some cases, address the cause of the diagnosis.


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regarding your proposed diagnoses. . .

impaired nutrition: less than, but there are really no noc's that i like for this patient

feeding and food intake is not a problem anymore since the patient has a gastric tube. nocs (outcomes) are based upon the etiologies of the problem and aren't done until
step #3 planning
. this is why you really need to be doing thorough patient assessment, which as i explained above, is much more than just a physical exam and review of systems on the patient. you have to know what the medical disease/condition is, its pathophysiology and complications. outcomes address the etiology (cause) of the problem and in many cases they are the anticipated results of your independent nursing actions to treat the symptoms of the problem. everything goes back to what you found in step #1 of the assessment.

ftt is dependent on the cp

is it? what was the cause of this patient's ftt? read the page in the merck manual on ftt. parental abuse is also a cause of ftt. if someone deliberately stops feeding a child because it is too much of a bother for them to do the complicated feeding of a child with swallowing problems, that's ftt too. there are many causes for ftt.

pain, acute

no evidence to support using this diagnosis. where is the pain?

  • observe her physical responses

    • behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility

    • sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis

    • parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness

where is the pain located? hw often does it occur? what triggers it? what relieves it?

how bad is it so you can determine if she needs interventions?

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Thanks so much! This changes the way I think about this case now. When I was reading about FTT, I read that it can be related to the CP, so I automatically went there. I really like the delayed growth and development diagnosis but can't fit a NOC to it. We have to use Nanda, NIC and NOC. There is one for Child Development: 12 months. The indicators are all age appropriate developmental tasks for a 12 month old. Of course, my patient is not functioning at this level and with her physical and mental issue, probably never will be, so how can I make a care plan working toward unrealistic goals. For example: pulls to stand - she has severe hypotonia and can't roll over by herself. Am I totally missing the boat here?

Thanks for your help.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

this is why i gave you weblinks for developmental tasks for a 3-month old. you need to look at what the expected developmental tasks are for a normal 14 month old child. the closest i could find online was for a 12 month old. what is your patient lacking? those are her developmental lags and symptoms for the delayed growth and development diagnosis. now, your interventions will be to look at what she can do. look at the websites. what are they saying you need to do with children to encourage them to move forward in their growth and development? read the websites about what kind of play and activities to engage in with them. those are your nics (interventions). what are the expected nocs with this? there is also a noc for child development: 4 months which is about where the developmental age of your patient is. these are the nocs listed (page 195, nursing outcomes classification (noc), third edition, by sue moorhead, marion johnson and meridean):

  • holds head erect and raises body on hands while in prone position
  • controls head well
  • rolls over from prone to supine
  • holds own hands
  • grasps rattle
  • reaches for objects
  • bats at objects
  • babbles and coos
  • recognizes parents voices
  • recognizes parents touch
  • looks at and becomes excited by mobile
  • smiles, laughs and squeals
  • sleeps for at least 6 hours
  • comforts self (e.g., falls asleep by self without breast or bottle)

the nocs for a diagnosis like risk for impaired verbal communication r/t impaired ability to articulate secondary to cerebral palsy which is an anticipated problem is to prevent the problem from happening. interventions are

  • strategies to prevent the problem from happening in the first place
  • monitoring for the specific signs and symptoms of this problem
  • reporting any symptoms that do occur to the doctor or other concerned professional

you can find more on developmental milestones and interaction with babies on the pediatric websites posted on this sticky thread: https://allnurses.com/nursing-student-assistance/medical-disease-information-258109.html - medical disease information/treatment/procedures/test reference websites

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Thanks soooo much for all your help. This helps a lot. :bow:

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