Pneumonia diagnoses help!

Published

I had a 17 month old baby whose chief complaint was: recurrent pneumonia and the diagnosis was: pneumonia w/respiratory distress.

the top two diagnosis i was thinking about are

Ineffective breathing pattern r/t presence of tracheo-bronchial secretions and nasal secretions AEB Irregular respirations: tachypnea (36 resps, 42 resps), Got congested at night- green mucus, Cough is productive- clear mucus, wheezes and rhonchi heard throughout, Some use of accessory muscles, CO2: 19L; FLACC Pain score 10/29: 3, NIPS pain score: 10/30: 1,

Acute pain R/T persistent hoorifice coughing AEB FLACC Pain score 10/29: 3,

NIPS pain score: 10/30: 1, Irritability, restlessness, VS: 35.4 C temporal, 82 bpm, 36 resp, 98 pulse ox.

Do you think these will be okay?

Up Vote Up Vote ×
Specializes in PICU, Sedation/Radiology, PACU.

Ineffective breathing pattern r/t presence of tracheo-bronchial secretions and nasal secretions AEB Irregular respirations: tachypnea (36 resps, 42 resps), Got congested at night- green mucus, Cough is productive- clear mucus, wheezes and rhonchi heard throughout, Some use of accessory muscles, CO2: 19L; FLACC Pain score 10/29: 3, NIPS pain score: 10/30: 1,

The ineffective breathing pattern isn't directly related to the secretions in the bronchi. The increased secretions are a result of the bacterial/viral pneumonia. Pneumonia affects the alveoli. The consolidation of bacteria and fluid collapses the alveoli, inhibiting gas exchange. So oxygen can't be diffused into the blood stream, which means the child has to work harder to breathe. The increased secretions are partly a result of the infection and partly the immune system process.

Choose your AEB data based on the ones that specifically affect the breathing pattern. Does the FLACC scale tell you that the patient is having trouble breathing? No, it tells you pain. Does a productive cough indicate that the breathing pattern is ineffective? A cough means that the child is appropriately attempting to clear the airway. What is the depth and quality of the respirations? Is their nasal flaring? Grunting? Retractions? What's the O2 saturation on room air? What does the chest x-ray look like? In babies, irritability can also be a sign of poor respiratory function. Also consider the diagnosis of Impaired gas exchange as a better fit.

Acute pain R/T persistent hoorifice coughing AEB FLACC Pain score 10/29: 3,

NIPS pain score: 10/30: 1, Irritability, restlessness, VS: 35.4 C temporal, 82 bpm, 36 resp, 98 pulse ox.

I'm not sure I would use this diagnosis. While I think that the child could have having pain from the coughing, I'm not convinced that you have enough evidence for it. The FLACC scale is a good tool, but the NIPS is recommended for infants less than one year of age. Your child is 17 months. And a NIPS score of 1 is extremely low. Also, your vital signs are all within the normal range. (35.4? Your child had a temporal temp of 96? That's awfully low.) HR is normal. Respirations are just a touch above normal (and can be attributed to the resp distress). Pulse ox isn't related to pain.

Why don't you try the diagnosis of "Ineffective airway clearance" instead? Especially if the child requires oral or nasal suctioning.

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

now, listen up, because what i am telling you next is very important information and is probably going to change your whole attitude about care plans and the nursing process. . .a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems

https://allnurses.com/general-nursing-student/help-care-plans-286986.html

to quote assistance from other members rn writer and daytonite. they offer a volume of assistance also search this site there are plenty of care plans already hashed out. here are a couple of good sites.

http://www.csufresno.edu/nursingstudents/fsnc/nursingcareplans.htm

www.pterrywave.com/nursing/care%20plans/nursing%20care%20plans%20toc.aspx

Up Vote Up Vote ×
+ Add a Comment