Two nursing diagnosis

[rrwill23]

I am struggling to find two nursing diagnosis for a healthy 7 mo old the only two that i came up with were risk for infection because his mom does not get him immunization and risk for falls because he is starting to crawl. are these strong nursing diagnosis

Risk for infection r/t lack of immunization AEB pt mom does not get immunization d/t cultural beliefs

Risk for falls r/t increased mobility AEB pt is starting to crawl.

any suggestions on diag or interventions?? Thanks!!!

[FORTHELOVEOF!!!!]

Can you give more info? I know you said healthy but define healthy. Why are they your patient, there has to be more to it.

[Esme12, ASN, BSN, RN]

welcome to an the largest online nursing community!

what semester are you? it sounds like you are falling into the typical trap of fitting the patient into the diagnosis instead of letting your assesment guide the diagnosis. how has this infant come into your care? you need to know the pathophysiology of your disease process. you need to assess your patient, collect data then find a diagnosis. let the patient data drive the diagnosis. what is your assessment?

the medical diagnosis is the disease itself. it is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. it is trying to teach you how to think like a nurse. think of them as a recipe to caring for your patient. your plan of how you are going to care for them.

from a very wise an contributor daytonite.......

every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the nanda taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. you need to have access to these books when you are working on care plans. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics.

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 adls, 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)
   

care plans must be chosen from the "approved" script....nanda. i think the biggest mistake students make is that the need to let what the patient says, does and feels (the assessment) dictate what you do next. not the medical diagnosis and try to fit the patient into diagnosis.

what information do you have?

[rrwill23]

I am in my second semester. We were doing a well baby clinic all the baby were fine

[Esme12, ASN, BSN, RN]

The Mom had no concerns? The baby has no siblings? The baby has never been sick? What milestones are there met or to be met? Is the baby in daycare? No teething?

Risk of falls.....I hope not. But that brings up a point such as knowledge deficit of caregiver/parent in protecting babies new milestones on the horizon and how to maintain a safe environment. Time to baby proof the home, light sockets, tchotchkes to get out of reach and off the floor.

I would think a risk for injury or the babies safety due to increased mobility would be more appropriate. Baby is also bigger is the car seat big enough? Is is begin used properly? Bath safety is huge, crib safety is huge. risk of impaired skin integrity for lacerations/abrasions as baby learns to furniture surf and meet with the edge of the coffee table/fireplace stone.

What about the new found awareness in babies development? This is the stranger fear begins in it's fullest.

Finger foods there is a risk of choking with new found finger foods. Risk of choking from small objects.... babies put everything in their mouths. (risk of aspiration) Are there pets in the environment? babies increased mobility can make the baby the target especially when a baby tries to make nice puppy and crawls after the dog in play.

Pain? Is the baby teething? Think Erickson's growth and development...what does this baby need. The link are the babies milestones and interventions for parent or to teach parents about their baby.

Risk for infection r/t insufficient knowledge regarding avoidance of exposure to pathogens AEB lack of immunizations d/t cultural beliefs.

http://www2.ed.gov/parents/earlychild/ready/healthystart/sevenmonth.pdf

What do you think? I hope this helps.

[rrwill23]

Thanks this helps

[Esme12, ASN, BSN, RN]

You're welcome.

[rrwill23]

how do you delete this post i reposted it under?

[Esme12, ASN, BSN, RN]

You can't. You can go to the help desk at the bottom of the page and request the administrators to remove the post.