Question

Please help

Please help to fill out nursing care plan for this patient who is Hydrocephalus with VP shunt. I give you 2 nursing diagnoses so help me to finish all another part. You can change nursing diagnosis if you think which better diagnosis for this patient

Nursing Care Plan

Patient Medical Diagnosis: Hydrocephalus with VP shunt

I. Nursing Diagnosis #1: Ineffective breathing pattern R/T disease process, tracheal dependency,

1. Assessment Data (include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)

a.

b.

C.

Goals & Outcome

(Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; measurable ; time- specific; and reasonable.)

Statement #l

Statement #2

Nursing interventions

(List at least three nursing or collaborative interventions with rationale for each goal & outcome.)

1.

2.

3.

1.

2.

3.

Rationale

(Provide reason why intervention is

indicated/therapeutic; provide references.)

Outcome Evaluation & Replanning

(Was goal met? How would you revise the plan of care according the patient's response to current plan ?)

Outcome#l

Outcome#2

II. Nursing diagnosis # 2: Potential for nutrition deficits R/T reliance on tube feeding

1. Etiology of problem
2. Subjective data
3. Objective data
4. Patient goals outcome
   1. Short terms goals
   2. Long terms goals

Answer 1

Nursing diagnosis 1. Ineffective tissue perfusion related to decreased blood flow as evidenced by irritability and decreased pulse or respiration.

ASSESSMENT DATA: Subjective data: the Mother complaints that the patients show more irritation and shrill crying and also shows difficulty in feeding. Objective data: (1st) on Observation it is understood that the Patient pulse rate and respiratory rate is decreased. (2nd) increased intracranial pressure. (3rd) evidence of abnormal large head with visible veins. (4th) patient looks lethargic.(5th) loss of consciousness

GOALS AND OUTCOME: Statement1: The child/ patient will demonstrate improved brain function as evidenced by normal vital signs Statement 2: The child/ patient will show improvement of alertness and cry, no further deterioration in the level of consciousness.

NURSING INTERVENTION: 1. Assess vital signs hourly, notify for any irregularity in breathing and heart rate, rhythm and measure pulse pressure. 2. Assess neurological status (such as mental status, motor and balance, reflexes (for newborns). 3. Examine the pupil by noting its size and reaction. 4. Elevate the head of the bed gradually by 15-20 degree as indicated 5. Provide oxygen therapy

RATIONALE: 1. Monitoring vital signs closely to recognize early signs of increased intracranial pressure (such as fluctuating blood pressure, tachycardia, and shallow breathing) or Cushing’s triad (bradycardia, apnea, and widening pulse pressure). 2. It will determine changes in child neurological conditions associated with ICP. 3. Pupil reaction which is controlled by the cranial nerve III (Oculomotor nerve) is beneficial for assessing brain stem function. 4. This position will reduce arterial pressure by promoting venous drainage and enhance cerebral perfusion. 5. Supplemental oxygen decreases hypoxemia level, which may improve cerebral Vasodilation and blood volume.

OUTCOME EVALUATION AND REPLANNING: Outcome 1: The child/ Patient shows responses to the therapeutic measures and vital signs are improved Outcome 2: The child shows improvement in their consciousness, alert and silent in nature.

Nursing diagnosis 2: Risk for infection related to invasive procedures of shunt insertion as evidenced by redness in the shunt tract.

ASSESSMENT DATA: Subjective data: Child is lethargic and poor feeding as Verbal response by his mother Objective data: Excessive drainage on dressing Elevated temperature Lethargy Vomiting Poor feeding Redness at shunt tract or operative site Swelling

GOAL AND OUTCOME: Outcome 1: Child/Infant will remain free of infection as evidenced by an absence of signs & symptoms of infection such as fever and laboratory studies related to infection within the normal limits. Outcome2: Child will demonstrate tolerance in feeding.

NURSING INTERVENTIONS: 1. Assess site for inflammatory process, temperature elevation, increased WBC, characteristics of drainage on dressings. 2. Monitor temperature every four (4) hours. 3. Follow Principles of aseptic technique when performing procedures such as dressing changes. 4. Teach parents about wound care and dressing change, emphasize the importance of good hand washing techniques.

RATIONALE: 1. Provides data indicating presence or potential for infection, which affects shunt function. 2. Elevation of temperature indicates infection. 3. Prevents transmission of microorganisms to shunt site. 4. Provides clean, sterile dressings when soiled or wet.

OUTCOME EVALUATION AND REPLANNING: Outcome 1. The child/ Patient shows responses to the therapeutic measures and vital signs are improved Outcome 2: The child will able to tolerate feeding