information…may be attributed to pathophysiological or situational causes that
are either temporary or permanent” (McDougall in. Ackley & Ladwig p. 538,.
INDIANA WESLEYAN UNIVERSITY DIVISION OF NURSING CONCERNS LIST Student Name ___Lori Lewis_____________________ Course____NUR 257____________ Client’s Initials____B. W.____ Date ___2/8/10____
Assessment Strengths
Cultural
Developmental
Identified Client Stressors
Risk and Family History
Time away from school during hospital stay Inability to remember first half of day
Risk for sleep deprivation
Diversional activity coloring Activity appropriate to age No psychiatric problems Normal hearing Normal vision Normal speech patterns Appropriate body weight School grade normal for age
Covered by health insurance Normal diet prescribed Clear conversation
Time away from siblings and friends during hospital stay
Permanent local residence English primary language 2 siblings
Write one prioritized nursing diagnosis in PES * format and include its definition.
Impaired memory related to neurological disturbances, as evidenced by inability to recall events. -NANDA definition: “Inability to remember or recall bits of information…may be attributed to pathophysiological or situational causes that are either temporary or permanent” (McDougall in Ackley & Ladwig p. 538, 2008). Readiness for enhanced communication as evidenced by expression of feelings and satisfaction with ability to share ideas with others. -NANDA definition: “A pattern of exchanging information and ideas with others that is sufficient for meeting one’s needs and life’s goals and can be strengthened” (Ladwig in Ackley & Ladwig p. 221).
Psychosocial
Parents attentive in room Standard precautions Alertness Oriented to person, place, time
Shyness Anxiety related to admission to hospital Isolation in hospital room
Awake Ability to understand commands Ability to talk
No professed religion
Risk for isolation in hospital
Ability to sit up Immunizations all up to date Flu vaccine current Blood pressure within normal limits Pulse within normal limits No pain Temperature decreased to normal level
Medical diagnosis of croup Sore throat High white blood cell count Low creatinine level Active IV infusion Active antibiotic therapy Low food and oral fluid intake
Risk for infection at IV site Risk for febrile seizures Risk for adverse effects of medications Smoking exposure at home Family history of seizures Family history of diabetes Family history of headaches Family history of cardiac problems
Spiritual
Risk for impaired social interaction
Physiological
Impaired social interaction related to therapeutic isolation. -definition: “Insufficient or excessive quantity or ineffective quality of social exchange” (Ladwig in Ackley & Ladwig p. 763). Risk for spiritual distress related to lack of connection with a religion. -NANDA definition: “At risk for an impaired ability to experience and integrate meaning and purpose in life through connectedness with … a power greater than oneself” (Burkhart in Ackley & Ladwig p. 782). Risk for deficient fluid volume related to hyperthermia. -NANDA definition: “At risk for experiencing vascular, cellular, or intracellular dehydration” (Ackley in Ackley & Ladwig p. 379).
*PES – Problem – Etiology – Signs and Symptoms [Nursing Diagnosis Label + Related to Factors (R/T) + As Evidenced By (AEB) Factors]
INDIANA WESLEYAN UNIVERSITY PLAN OF CARE Student Name ___Lori Lewis ____________________ Course__NUR 257______________ Client’s Initials____B. W.______ Date __2/8/10__ Medical Diagnosis and Problem List Medical Diagnosis: Croup with febrile seizures.
Assessment: Data Base Intrapersonal Factors
Diversional activity- coloring Activity appropriate to age No psychiatric problems Normal hearing Normal vision Normal speech patterns Appropriate body weight Inability to remember first half of day Risk for sleep deprivation Temperature decreased to normal level Normal diet prescribed Permanent local residence Alertness Anxiety related to admission to hospital Awake Ability to sit up Immunizations all up to date Flu vaccine current Blood pressure within normal limits Pulse within normal limits No pain Medical diagnosis of croup Sore throat
Interpersonal Factors
School grade normal for age Time away from school during hospital stay Clear conversation Time away from siblings and friends during hospital stay 2 siblings Parents attentive in room Shyness Isolation in hospital room Risk for impaired social interaction Ability to understand commands Ability to talk Risk for isolation in hospital Smoking exposure at home
Extrapersonal Factors
Covered by health insurance English primary language Standard precautions Oriented to person, place, time No professed religion Family history of seizures Family history of diabetes Family history of headaches Family history of cardiac problems
Risk for infection at IV site Risk for febrile seizures Risk for adverse effects of medications High white blood cell count Low creatinine level Active IV infusion Active antibiotic therapy Low food and oral fluid intake
Nursing Diagnosis Risk for deficient fluid volume related to hyperthermia.
Goals Short Term Goal Client will maintain normal blood pressure, pulse, and body temperature throughout clinical day.
Interventions Primary 1. Student nurse will monitor blood pressure, pulse, and body temperature throughout clinical day.
Secondary 1. Nurse will administer antipyretics as prescribed.
Long Term Goal Client will maintain elastic skin turgor and fluid intake of 30 mL/kg of body weight for one week following admission to hospital.
Tertiary 1. Student nurse will educate client’s parents about the importance of adequate fluid intake and signs of dehydration, such as decreased skin turgor, which need to be reported.
Scientific Rationale 1. “Early identification of risk factors and early intervention can decrease the occurrence and severity of complications from deficient fluid volume” (Metheny in Ackley & Ladwig, p. 380). 1. “…temperature elevation is … accompanied by an increase in oxygen consumption and metabolic rate that may not be tolerated by the acutely ill client” (Henker & Carlson in Ackley & Ladwig, p. 436). 1. “Oral rehydration therapy is effective for treating mild to moderate dehydration” (Larson in Ackley & Ladwig, p. 373).
References: Ackley, B. & Ladwig, G. (2008). Nursing Diagnosis Handbook. St. Louis, MO: Mosby Elsevier.
Evaluation of Goals Short Term Client’s blood pressure, pulse, and body temperature were within normal range upon measurement by student nurse at the end of the day.
Long Term Unable to evaluate due to end of clinical period. Would evaluate by the parent’s statement of the client’s fluid intake, and measurement of skin turgor by student nurse.
