you are approaching the writing of this care plan in the wrong way. a doctor diagnoses by first assessing and evaluating the symptoms the patient has. the symptoms determine the diagnosis. the definition of a diagnosis, any diagnosis, is the resulting decision or opinion that is made after the process of examination or investigation of the facts has been performed. car mechanics do this. plumbers do this. and, nurses do this as well. every nursing diagnosis has a determined set of criteria (symptoms) and a definition. in order to label someone with a particular nursing diagnosis they must have the requisite symptoms. to determine your patient's nursing diagnoses you must first put all your assessment data that you have collected in front of you. you are going to be interested in the abnormal data. the abnormal data is what are actually your patient's symptoms that you will work with to determine the nursing diagnoses. from the 4 posts that you made to this thread i can list this abnormal data:
- something about csf cultures - you need to be more specific about what these csf cultures showed - was there a bacteria present?
- patient is irritable
- patient is not tracking
- patient has a fever - what are the readings on these fevers, how high have they gone?
are there more that you haven't listed or that you inadvertently excluded? go back through your assessment again to see if you missed something. since the doctor has said the patient has meningitis, he saw specific signs and symptoms that led him to this decision. did you see them too? did this patient have any of the following?
- nausea, vomiting
- profuse sweating
- any change in level of consciousness
- cranial nerve palsies
- symptoms of increased icp
- refusal to eat
- high-pitched crying
refusing to eat, irritability and high-pitched crying is common in neonates with meningitis. what are you doing about addressing nutrition? part of doing your care plan should be to investigate and read about meningitis in children because you need to know the pathophysiology of this disease to understand why the doctor is ordering the treatments and medications for the baby. what the doctor has ordered should also be clues for you to pursue as to symptoms you might have missed that the doctor is treating. it will also help you to understand the etiologies of some of the symptoms the baby has.
with your list of symptoms you look to match them with suitable nursing diagnoses. you say you are using a nursing diagnosis of acute pain
yet you listed no abnormal data that indicated that the baby has pain unless you were meaning to use the irritability as in acute pain r/t inflamed meninges aeb irritability.
since this is a one-month old, did you do an assessment of the baby's development? this website has a link to age specific behavior parameters for children up to one year of age: http://www.baptistonline.org/health/library/child.asp
that you can assess your patient against. are you also supposed to assess a pediatric patient according to erikson's developmental stages? that would give you more definitive information as to whether this child has any developmental delays at this time. there is also a nanda nursing diagnosis of risk for delayed development
. its definition is at risk for delay of 25% or more in one or more of the areas of social or self-regulatory behavior, or in cognitive language, gross or fine motor skills.
the risk factors include prenatal ones (endocrine disorders, genetic disorders, illiteracy, inadequate nutrition, infections, lack of prenatal care, late prenatal care, maternal age less than 15 years or over 35 years of age, poor prenatal care, poverty, substance abuse, unplanned pregnancy, and unwanted pregnancy), individual ones (adopted child, behavior disorders, brain damage as a result of such things as hemorrhage in the postnatal period, shaken baby, abuse or an accident, chemotherapy, chronic illness, congenital disorders, failure to thrive, foster child, frequent otitis media, genetic disorders, hearing impairment, inadequate nutrition, lead poisoning, natural disasters, positive drug screens, prematurity, radiation therapy, seizures, substance abuse, technology-dependency, and vision impairment), environmental ones (poverty, violence), and caregiver ones (abuse, mental illness, mental retardation, and severe learning disability). [nanda-i nursing diagnoses: definitions & classification 2007-2008
published by nanda international, page 70]
there is information on writing care plans and how to chose nursing diagnoses in the student nursing forums on these two threads: