Please help me :(

[rosemary_petals]

Working on a care plan. My patient was a three year female with cellulitis of the left knee. The patient chief complaints were fever, n&v, and pain of the left knee. The patient was given antibiotics. She was actually getting ready to be d/c when I came that morning.

(I still have to do a ncp, however ] Everything looked good, v/s are stable, extremities look good and reports no pain.

I am trying to come up with SOMETHING and it is soooo hard!

The only problem i did notice was the following:

The patient kept refusing to take her medication.

The patient had anxiety when leaving the room to go to play room because she wanted to be in her regular clothing and not hospital clothing. also seemed overwhelmed by new environment.

The patient's mother wanted child's iv to be discontinued because child was tired of it being in arm. She requested a pill form of vanco (no mam)

The only nursing dx I could come up with was:

non-compliance related to cognitive deficit AEB patient too young to understand purpose of medication.

non-compliance related to procedure AEB patient verbalize uncomfortable feeling of iv

anxiety r/t change in environment.

Im not asking for answers just wanted to know if I am heading in a good direction?

[Nolli]

You are heading in the right direction, but I would reformat the Dx. Look back at what you noticed. You stated that the child was anxious and overwhlemed. What psychosocial diagnoses do you see related to that? Also remember that you treat the whole family, not just the child. What are you going to do about mom's request? What does she need?

[KRVRN, BSN, RN]

Well is Non-compliance correct? Those actions are fairly developmentally appropriate.

[nurseprnRN, BSN, RN]

No, you cannot make a nursing diagnosis of "noncompliance" in a three-year-old alone. They're all too little; they can't make any decisions bigger than what to wear and what kind of juice they want :). Have you looked at the defining characteristics in NANDA-I 2012-2014 for this diagnosis? None of them are "cognitive deficit," so did you make that up? You can't make up nursing dx.

In this case, it would count the parent, too, but I'm not seeing failure to adhere to a health-promoting or therapeutic plan.

It's late and I can't go and find my explanation of NANDA-I 2012-2014 and why you have to adhere to it (!) but you won't have to look too far here to find it.