Care_planning_1 Peds Dn Age 17

Care Planning Student: Patient’s Age: 17 Key Problem Patient Response #1

Key Problem Patient Response #2

Nrs. Dx: Ineffective protection: anemia Risk for imbalanced

Patient verbalized he has trouble seeing out of his left eye. Nrs. Dx: Vision loss related to retinal detachment

fluid volume related to failure of regulatory mechanisms AEB: decreased serum albumin level Assessment Data: : Edema of the extremities and face, specifically in the periorbital region. Concentrated urine output (urine is dark amber in color). Patient has swelling present in periorbital region, and complains of facial discomfort around eyes, bilaterally Treatments:: Monitor input and output closely. Evaluate urine output in response to diuretic therapy, Institute/instruct patient regarding fluid restrictions as appropriate, Restrict diet 2 g sodium intake as prescribed.

PMH report of retinal detachment in the left eye. Assessment Data: * patient stated that he could not see the pen light when flashed into his left eye, visible redness and PERRLA unilateral no response, in left eye. PMH of retinal detachment in left eye AEB:

Inform the patient not to rub his eye, provide adequate lighting. Place meal tray, water and call device within the patients’ range of vision or reach. Make appropriate referrals to ophthalmologist and social services for follow up. Medications:: None prescribed Treatments:

Albumin human 25 gm, IVPB bid, furosemide IVPB 80 mg/daily, prednisone, 40 mg oral, bid. Medical Hx: Nephrotic syndrome Medications:

Nephrotic syndrome, Sturge-Weber syndrome Medical Hx:

Reason the Patient Needs Health Care

Medical Dx: Nephrotic syndrome, SturgeWeber syndrome Priority Assessments:

I & O’s (256 ml-in, 100 ml-out pt missed one void), BP 120/63, HR 77, cap refill <3 sec, RR 20, T 36.7, SaO2 100%. Trace ketones in urine. BUN 31 (norm 817) RBC’s 4.28, (norm 4.6), Hct 35.1 (norm 37-49), Hgb 12.3 (norm 1316) albumin level 2.1 (norm 4.0-5.8) port wine stain surrounding left side of face/eye. Lung sounds clear to auscultation. Peripheral pulses present radial, pedal +2. Family not involved. Diet (2g Na/day)

Key Problem Patient Response #3

Key Problem Patient Response #4

Patient stated that he has a throbbing pain in his lower back.

Patient stated that he would like to take better care of himself, but he doesn’t have health insurance to cover medication cost.

Acute pain resulting from medical treatments Nrs. Dx:

AEB:

patients verbal complaint of lower back pain Patient rates pain as a 6 on a scale of 1-10, where 10 is the worst pain ever felt. Patient does not want pharmacological relief from pain. Patient expresses pain occurs when given albumin therapy treatment. Assessment Data:

Nonpharmacologic method of relaxation exercises, breathing techniques and repositioning. Treatments:

Medications:

none prescribed, patient refused referral to physician for pain medication: Medical Hx: : Nephrotic syndrome

: Ineffective health maintenance related to lack of financial resources AEB: Patient stating he has no prescription coverage or health insurance Nrs. Dx:

Assessment Data:

Patient states that he has limited ability in performing the normal activities of daily living * Patients’ health history over past 5 years shows that he is noncompliant with health advice in regards to maintenance of his disease. * Patient states that his environmental, social and interfamilial disruptions have correlated with poor health behaviors. Assessment complaints are directly related to lack of financial resources. Treatments: Provide patient with a means of contacting health care providers. Discuss noncompliance with instructions or programs with patient to determine rationale for failure. This will add available resources for questions or problem resolution. Also inform patients’ primary caregiver of MiChild free insurance carrier for minors to help supplement cost for care and medications. Medications: none prescribed Nephrotic syndrome, Sturge-Weber syndrome, Chlamydia, gonorrhea Medical Hx: