Nursing Care plan

nursing case study and need the explanation and answer to help me learn.

please fill out the documents on information given. If no info for the area pleaze put N/A.
Requirements: answer question
NAANDA APPROVED NURSING DIAGNOSES
PHYSICAL PROBLEMS
BOWEL
Bowel incontinence
Constipation
Colonic constipation
Perceived constipation
Constipation, Perceived
Constipation, Risk for
Constipation, Chronic Functional
Constipation, Risk for Chronic Functional
Contamination
Contamination, Risk for
Diarrhea
Gastrointestinal Motility, Dysfunctional
Gastrointestinal Motility
Risk for Dysfunctional Gastrointestinal
Perfusion, Risk for Ineffective
CIRCULATION
Tissue Perfusion, Ineffective Peripheral
Tissue Perfusion, Risk for Ineffective Peripheral
Tissue Perfusion, Risk for Decreased Cardiac
Tissue Perfusion, Risk for Ineffective Cerebral
Bleeding, Risk for
Cardiac Output, Decreased
Cardiac Output, Risk for Decreased
Cardiovascular Function, Risk for Impaired
Shock, Risk for
Surgical Recovery, Delayed
Surgical Recovery, Risk for Delayed
Vascular Trauma, Risk for
FLUID/HYDRATION
Fluid volume deficit
High risk for fluid volume deficit
Fluid volume excess
Fluid Volume, Risk for Deficient
Fluid Volume, Risk for Imbalanced
Fluid Balance, Readiness for Enhanced
Electrolyte Imbalance, Risk for
ENDOCRINE
Blood Glucose Level, Risk for Unstable
INFANT FEEDING/BREASTFEEDING PROBLEMS
Effective breast-feeding
Ineffective breast-feeding
Interrupted breast-feeding
Ineffective infant feeding pattern
Insufficient Breast Milk
Readiness for enhanced Breastfeeding,
Liver Function, Risk for Impaired
Jaundice, Neonatal
Jaundice, Risk for Neonatal
Sudden Infant Death Syndrome, Risk for
Suffocation, Risk for
MOBILITY ACTIVITY
Activity Intolerance
High risk for activitiy intolerance
Diversional activity deficit
High risk for disuse syndrome
Transfer Ability, Impaired
Activity Intolerance
Activity Intolerance, Risk for
Activity Planning, Ineffective
Activity Planning, Risk for Ineffective
Decreased Intracranial Adaptive Capacity
Lifestyle, Sedentary
Mobility, Impaired Bed
Mobility, Impaired Physical
Mobility, Impaired Wheelchair
Sitting, Impaired
Standing, Impaired
Walking, Impaired
Wandering
NEUROLOGIC DYSFUNCTION
Autonomic Dysreflexia
Autonomic Dysreflexia, Risk for
Memory, Impaired
Peripheral Neurovascular Dysfunction, Risk for
NUTRITION/EATING
Nutrition, Imbalanced: Less than Body Requirements
Nutrition, Readiness for Enhanced
Obesity
Risk for Overweight
Overweight
Nausea
Swallowing, Impaired
PAIN
Pain, Acute
Pain, Chronic
Pain Syndrome, Chronic
Pain, Chronic Malignant
Pain, Chronic Nonmalignant

PHYSICAL SAFETY/PROTECTION
Altered protection
Dysreflexia
High risk for infection
High risk for injury
High risk for poisoning
High risk for trauma
Trauma, Risk for
Sensory/perceptual alterations
Unilateral neglect
Infection, Risk for
Injury, Risk for Corneal
Falls, Risk for
Injury, Risk for Perioperative-Positioning
Injury, Risk for Thermal
Injury, Risk for Urinary Tract
Self-Mutilation
Self-Mutilation, Risk for
Suicide, Risk for
RESPIRATORY/BREATHING
Airway Clearance, Ineffective
Allergy Response, Risk for
Risk for Aspiration,
High risk for suffocation
Inability to sustain spontaneous ventilation
Dysfunctional ventilatory weaning response
Ineffective airway clearance
Ineffective breathing pattern
Spontaneous Ventilation, Impaired
Ventilatory Weaning Response, Dysfunctional
REST/SLEEP
Fatigue
Sleep, Readiness for Enhanced
Sleep Deprivation
Sleep Pattern, Disturbed
Insomnia
SELF-CARE
Bathing/Hygiene self-care deficit
Feeding self-care deficit
Toileting self-care deficit
Self-Care, Readiness for Enhanced
Self-Care Deficit, Bathing
Self-Care Deficit, Dressing
Self-Care Deficit, Feeding
Self-Care Deficit, Toileting
Self-Concept, Readiness for Enhanced
Self-Neglect
SEX/SEXUALITY
Altered sexuality patterns
Sexual dysfunction
Sexuality Pattern, Ineffective

SKIN/MUCOUS MEMBRANE
Impaired Oral Mucous Membrane
Risk for Impaired Oral Mucous Membrane
High Risk for impaired tissue integrity
Impaired tissue integrity
Dry Eye, Risk for
Skin Integrity, Impaired
Skin Integrity, Risk for Impaired
Latex Allergy Response
Latex Allergy Response, Risk for
Pressure Ulcer, Risk for
TEMPERATURE
Body Temperature, Risk for Imbalanced
High risk for altered body temperature
Hyperthermia
Hypothermia
Hypothermia, Risk for
Hypothermia, Risk for Perioperative
Reaction to Iodinated Contrast Media, Risk for
Protection, Ineffective
Thermoregulation, Ineffective
URINARY/VOIDING
Altered urinary elimination
Reflex incontinence
Total incontinence
Urinary retention
Elimination, Readiness for Enhanced Urinary
Incontinence, Functional Urinary
Incontinence, Overflow Urinary
Incontinence, Reflex Urinary
Incontinence, Risk for Urge Urinary
Incontinence, Stress Urinary
Incontinence, Urge Urinary
Renal Perfusion, Risk for Ineffective
PSYCHOSOCIAL
COMMUNICATION, THINKING, KNOWLEDGE
Altered thought processes
Knowledge/skills deficit
Knowledge, Deficient
Knowledge, Readiness for Enhanced
Impaired verbal communication
Comfort, Readiness for Enhanced
Communication, Readiness for Enhanced
Confusion, Acute
Confusion, Chronic
Confusion, Risk for Acute
COPING/ADJUSMENT
Anxiety
Defensive coping
Ineffective individual coping
Coping, Compromised Family
Coping, Defensive
Coping, Disabled Family
Coping, Ineffective Community
Coping, Readiness for Enhanced
Coping, Readiness for Enhanced Community
Coping, Readiness for Enhanced Family
Diversional Activity, Deficient
Decisional conflict
Fear
Grieving
Anticipatory grieving
Dysfunctional grieving
Grieving, Complicated
Grieving, Risk for Complicated
Hope, Readiness for Enhanced
Hopelessness
Human Dignity, Risk for Compromised
Impaired adjustment
Ineffective denial
Power, Readiness for Enhanced
Powerlessness
Powerlessness, Risk for
Stress Overload
Relocation stress syndrome
Relocation Stress Syndrome, Risk for
Spiritual distress
Social Interaction, Impaired
Social Isolation
Sorrow, Chronic
Spiritual Distress
Spiritual Distress, Risk for
Spiritual Well-Being, Readiness for Enhanced
Religiosity, Impaired
Religiosity, Readiness for Enhanced
Religiosity, Risk for Impaired
Death Anxiety
Decision-Making, Readiness for Enhanced
Decisional Conflict
Denial, Ineffective
Emancipated Decision Making, Impaired
Emancipated Decision Making, Readiness for Enhanced Emancipated Decision Making. Risk for Impaired
Emotional Control, Labile
Impulse Control, Ineffective
FAMILY & GROWTH/DEVELOPMENT
Attachment, Risk for Impaired
Altered family processes
Family Processes, Dysfunctional
Family Processes, Interrupted
Family Processes, Readiness for Enhanced
Altered growth and development
Development, Risk for Delayed
Growth, Risk for Disproportionate
Altered parenting
High risk for altered parenting
Caregiver role strain
High risk for caregiver role straing
Family coping: potential for growth
Ineffective family coping: compromised
Role Conflict, Parental
Role Performance, Ineffective
Role Strain, Caregiver
Role Strain, Risk for Caregiver
Parenting, Impaired
Parenting, Readiness for Enhanced
Parenting, Risk for Impaired
Dentition, Impaired
Frail Elderly Syndrome
Frail Elderly Syndrome, Risk for
Resilience, Impaired
Resilience, Readiness for Enhanced
Resilience, Risk for Impaired
HEALTH MANAGEMENT
Altered health maintenance
Health-seeking behavior
Impaired home maintenance management
Ineffective management of therapeutic regimen
Noncompliance
Health, Deficient Community
Health Behavior, Risk-Prone
Health Maintenance, Ineffective
Health Management, Ineffective
Health Management, Readiness for Enhanced
Health Management, Ineffective Family
Home Maintenance, Impaired
INFANT BEHAVIOR
Behavior, Disorganized Infant Behavior
Readiness for Enhanced Organized Infant
Behavior,
Risk for Disorganized Infant
Mood Regulation, Impaired
Loneliness, Risk for
Moral Distress
ROLE/RELATIONSHIP
Altered role performance
Impaired social interaction
Social Isolation
Relationship, Ineffective
Relationship, Risk for Ineffective
Relationship, Readiness for Enhanced
SELF-ESTEEM
Body image disturbance
Self-esteem disturbance
Chronic low self-esteem
Situational low self-esteem
Personal Identity, Disturbed
Personal Identity, Risk for Disturbed
Self-Esteem, Chronic Low
Self-Esteem, Risk for Chronic Low
Self-Esteem, Situational Low
Self-Esteem, Risk for Situational Low
VIOLENCE
High risk for self-mutilation
Self-Directed Violence, Risk For
Other-Directed Violence, Risk for
Post-trauma responses
Rape-trauma syndrome
Rape-trauma syntdrome: compound reaction
Post-Trauma Syndrome
Post-Trauma Syndrome, Risk for
MATERNITY
Childbearing Process, Ineffective
Childbearing Process, Readiness for Enhanced
Childbearing Process, Risk for Ineffective
Comfort, Impaired
Maternal/Fetal Dyad, Risk for Disturbed
Pain, Labor

Sample Type / Medical Specialty: Pediatrics – Neonatal
Sample Name: Ear pain – Pediatric Consult
Description: 13 years old complaining about severe ear pain – Chronic otitis media.
(Medical Transcription Sample Report)
PRESENTATION: Patient, 13 years old, comes to your office with his mother complaining about severe ear pain. He awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.

HISTORY OF PRESENT ILLNESS: Patient reports that he felt good after taking antibiotics with each earache episode and has recently started on the wrestling team. Mom reports that patient has been afebrile with each of the earache episodes, and he has not had upper respiratory symptoms. Patient denies any head trauma associated with wrestling practice.

BIRTH AND DEVELOPMENTAL HISTORY: Patient’s mother reports a normal pregnancy with no complications, having received prenatal care from 12 weeks. Vaginal delivery was uneventful with a normal perinatal course. Patient sat alone at 6 months, crawled at 9 months, and walked at 13 months. His verbal and motor developmental milestones were as expected.

FAMILY/SOCIAL HISTORY: Patient lives with both parents and two siblings (brother – age 11 years, sister – age 15 years). He reports enjoying school, remains active in scouts, and is very excited about being on the wresting team. Mom reports that he has several friends, but she is concerned about the time required for the wrestling team. Patient is in 8th grade this year and an A/B student. Both siblings are healthy. His Dad has hypertension and has frequent heartburn symptoms that he treats with over-the-counter (OTC) medications. Mom is healthy and has asthma.

PAST MEDICAL HISTORY: Patient has been seen in the clinic yearly for well child exams. He has had no major illnesses or hospitalizations. He had one emergency room visit 2 years ago for a knee laceration. Patient has been healthy except for the past year when he had two episodes of otitis media not associated with respiratory infections. He received antibiotic therapy (amoxicillin) for the otitis media and both episodes resolved without problems. Patient’s Mom states that he takes no prescribed medications or OTC medications, but he admits that he has been taking his dad’s OTC Pepcid AE sometimes when he gets heartburn. Upon further examination, he reports taking Pepcid when he eats pizza or Mexican food. He does complain of sore throats sometimes and often feels burning in his throat when he goes to sleep at night after a late evening snack.

NUTRITIONAL HISTORY: Patient eats cereal bars or pop tarts with milk for breakfast most days. He takes his lunch (usually a sandwich and chips or yogurt and fruit) for lunch. Mom or his sister cooks supper in the evening. The family goes out to eat once or twice a week and he only gets “fast food” once or twice a week according to his Mom. He says he eats “a lot” especially after a wrestling meet.

PHYSICAL EXAM:
Height/weight: Patient weighs 109 pounds (60th percentile) and is 69 inches tall (93rd percentile). He is following the growth pattern he established in infancy.
Vital signs: BP 110/60, T 99.2, HR 70, R 16.
General: Alert, cooperative but a bit shy.
Neuro: DTRs symmetric, 2+, negative Romberg, able to perform simple calculations without difficulty, short-term memory intact. He responds appropriately to verbal and visual cues, and movements are smooth and coordinated.
HEENT: Normocephalic, PEERLA, red reflex present, optic disk and ocular vessels normal. TMs deep red, dull, landmarks obscured, full bilaterally. Post auricular and submandibular nodes on left are palpable and slightly tender.
Lungs: CTA, breath sounds equal bilaterally, excursion and chest configuration normal.
Cardiac: S1, S2 split, no murmurs, pulses equal bilaterally.
Abdomen: Soft, rounded, reports no epigastric tenderness but states that heartburn begins in epigastric area and rises to throat. Bowel sounds active in all quadrants. No hepatosplenomegaly or tenderness. No CVA tenderness.
Musculoskeletal: Full range of motion, all extremities. Spine straight, able to perform jumping jacks and duck walk without difficulty.
Genital: Normal male, Tanner stage 4. Rectal exam – small amount of soft stool, no fissures or masses.

LABS: Stool negative for blood and H. pylori antigen. Normal CBC and urinalysis. A barium swallow and upper GI was scheduled for the following week. It showed marked GE reflux.

ASSESSMENT: The differential diagnoses for patient included (a) chronic otitis media/treatment failure, (b) peptic ulcer disease/gastritis, (c) gastro esophageal reflux disease (GERD) or carbonated beverage syndrome, (d) trauma.

CHRONIC OTITIS MEDIA. Chronic otitis media due to a penicillin resistant organism would be the obvious diagnosis in this case. It is rare for an adolescent to have otitis media with no precipitating factor (such as being on a swim team or otherwise exposed to unusual organisms or in an unusual environment). It is certainly unusual for him to have three episodes in 1 year.

PEPTIC ULCER DISEASE. There were no symptoms of peptic ulcer disease, a negative H. pylori screen and lack of pain made this diagnosis less likely. Trauma. Trauma was a possibility, particularly since adolescent males frequently minimize symptoms especially if they might limit participation in a sport but patient maintained that he had not had an event where he struck his head or neck and that he always wore his helmet with ear padding.

GERD. The history of “heartburn” relieved by his father’s medication was striking. The positive study supported the diagnosis of GERD, which was severe and chronic enough to cause irritation of the mucosal surfaces exposed to the gastric juices and edema, inflammation in the inner ears.

PLAN: Patient and his Mom agreed to a trial of omeprazole 20 mg at bedtime for 2 weeks. Patient was to keep a diary of any episodes of heartburn, including what foods seemed to aggravate it. The clinician asked him to avoid using any antacid products in the meantime to gage the effectiveness of the medication. He was also given a prescription for 10 days of Augmentin99 and a follow-up appointment for 2 weeks. At his follow-up appointment he reported one episode after he ate a whole large pizza after wrestling practice but said it went away pretty quickly after he took his medication. A 6-month follow up appointment was scheduled.

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