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Nursing Diagnosis

Student’s Name

Institutional Affiliation
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J.D.

What other assessments should be included for this patient?

 Cardiac assessment

 Head to food evaluation

 Abdominal evaluation

 Mental health evaluation

What questions should the nurse ask with regard to the abdominal pain?

 At what time is the abdominal pain at the worst? Is it worse before or after eating?

 Does the abdominal pain manifest more in the early morning or late at night?

 When did the abdominal pains start?

 Does the pain radiate to other body parts?

 Is the pain intermittent or continuous?

 Have you attempted any mitigatory procedures to lessen the pain?

 Are there accompanying symptoms such as nausea, itch, vomiting, or numbness?

From the readings, subjective data, and objective data, what is the most probable cause of

the abdominal pain?

 It is most likely a flare-up of Crohn’s disease with which he has been diagnosed.

The condition induces inflammation in the digestive tract leading to severe

diarrhea and abdominal pain.

Develop a problems list from the subjective and objective findings.

 Anorexia

 Diarrhea 8-10 times a day

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 Hyperactive bowel movement

 Lower abdominal pain on the right and left sides.

What should be included in the plan of care?

 Fluids to balance the deficit created by diarrhea

 Nutrition to alleviate diarrhea and anorexia

 Ongoing monitoring of vital signs, pain, and bleeding.

What interventions should be included in the plan of care for this patient?

 Steroids

 Diet and nutrition education

 Antidiarrheals

 Further diagnostics of stool culture, endoscopy, colonoscopy, and blood tests.

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S.P.

What other questions should the nurse ask?

 What parts of the leg ache?

 Is the pain localized in one leg or both?

 Are there positions or actions that alleviate the pain?

 When did the pain start? Is it worse in the morning?

What techniques are helpful to incorporate in assessing a patient in this age group?

 Involving the child’s parents in the diagnosis who can provide additional information

 Engaging the child in playful activities that reduce their tension

What other assessments should the nurse make for this clinical presentation?

 Biometric assessment of the patient’s height and weight

 Ear assessment to determine the recurrence of otitis media which has a relapse rate of

20% to 30%

 Nutritional assessment

 Pain assessment to help in planning the care plan.

What are a few of the major differences in the musculoskeletal assessment of a child?

 There is an emphasis on observation rather than performing tests.

 Parents provide most of the information required for retrospective diagnoses, such as

pregnancy and postnatal conditions

 Nurses conduct a simple MSK assessment (pGALS), which evaluates the extent to which

pediatric Gait, Arms, Legs, and Spin conform to developmental expectations.

What should be included in the plan of care?

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 Immunization

 Healthy diet

 Prevention of major injuries

Based on the readings, what is the most likely cause of leg pain for this patient?

The most likely diagnosis is growing pains as they happen from 3 – 4 years.
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D.F.

What other questions should the nurse ask about the seizures?

 When was the first seizure?

 Are recent seizures similar to the first? Worse? Less potent?

 Do you experience an ‘aura’ or other warning signs?

 What is your condition following a seizure?

 Do you have a family history of seizures?

What other assessments are necessary for this patient?

*Check for marks or ulceration on the side of the tongue or oral mucous membrane as can

be seen with seizures

 Neurological examination
 Lab tests for uremia, Hyponatremia, hypoglycemia, hypomagnesemia, and hepatic
encephalopathy which can catalyze seizures
 Measuring serum electrolytes
What are some of the causes of seizures?

 Head trauma

 Tumors

 Cerebral degeneration

 Genetics

 Stroke

Develop a problem list from objective and subjective data.

 Fatigue
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 Acute pain

 Impaired physical mobility

What should be included in the plan of care?

 Around the clock monitoring

 Patient’s bed has raised side rails

 Maintain open airways

 Patient and family education on injury-prevention measures during a seizure episode

What other risk factors are associated with this presentation?

 Metabolic imbalances

 Compromised nervous system

Based on the readings and the subjective and objective data, this patient most likely had

what type of seizure?

The most likely type is Psychogenic Non-Epileptic Seizures (PNES) which is more common

among the patient’s age group.

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References

Brown, R. J., & Reuber, M. (2016). Towards an integrative theory of psychogenic non-epileptic

seizures (PNES). Clinical psychology review, 47, 55-70.

Hryhorczuk, A. L., Restrepo, R., & Lee, E. Y. (2016). Pediatric musculoskeletal ultrasound:

practical imaging approach. American Journal of Roentgenology, 206(5), W62-W72.