Discussion: Nursing Diagnosis Handbook

Please do Parts A, B, C of the following case study. Upload
your results to the drop box

Ackley: Nursing Diagnosis Handbook, 11th Edition

Lecture Notes

Problem-Based Learning/Critical Thinking

Case Study – Carlo Stamm (Peanut Allergy)

Case Scenario

Carlo Stamm is a 10 year old boy who has known dairy
allergies. During a class trip to the local zoo last year Carlo was feeding
animals and rubbed his eyes without washing his hands. He began to complain of
itchiness around his eyes and there was noticeable periorbital swelling. One of
the chaperones on the class trip recognized the manifestations as an allergic
reaction and called Carlo’s mother. Carlo was taken by his mother to an urgent
care center where the primary care practitioner and nurse reviewed Carlo’s
history and assessed him.

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Nursing Assessment

Carlo Stamm is 10 years old with a BMI of 22. He is in the
fifth grade at a public school where a nurse is present on Tuesdays and
Thursdays. His vital signs are: blood
pressure – 102/62; temperature – 98.8 degrees F.; heart rate – 90 BPM; respirations
– 18 per minute. The nurse at the urgent center called the local zoo and
requested information on the animal food that Carlo handled. The animal food was composed of multigrains
and peanuts. Carlo was given
?diphenhydramine orally and his mother was given a prescription for an epinephrine
autoinjector. Carlo was observed for an hour and his periorbial edema subsided
as well as the itchiness. Carlo was drowsy from the diphenhydramine and taken
home to rest. Discussion: Nursing Diagnosis Handbook

A. ASSESS

1. Identify
significant symptoms by underlining them in the assessment.

2. List those
symptoms that indicate the client has a health problem (those you have
underlined).

3. Group the
symptoms that are similar.

B. DIAGNOSE

1. Select
possible nursing diagnoses for this client.

Do this by looking at the list of nursing diagnoses in, the
book, Ackley/Ladwig Nursing Diagnosis Handbook: An Evidence-Based Guide to
Planning Care or by accessing the care plan constructor at the EVOLVE SITE and
viewing nursing diagnoses listed there.
(You can copy and paste the information from the EVOLVE SITE
in the areas below.)

Possible nursing diagnoses:

2. Validate the
possible nursing diagnoses.

Compare the signs and symptoms (defining characteristics)
that you have identified from your client assessment with the defining
characteristics for the nursing diagnosis that you have selected. Also read the
definition and determine if this diagnosis fits this client.

Validated nursing diagnoses include:

3. Write/select a
nursing diagnostic statement for one of the nursing diagnoses by combining the
nursing diagnosis label with the related to (r/t) factors.

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a. The label is
the title of the nursing diagnosis as defined by NANDA.
b. A related to
(r/t) statement describes factors that may be contributing to or causing the
problem that resulted in the nursing diagnosis.

(You can copy and paste the information from the EVOLVE SITE
in the areas below.)

NANDA label:

Definition:
Risk Factors:
The complete nursing diagnostic statement is:

C. PLAN

Discussion: Nursing Diagnosis Handbook

Discussion: Nursing Diagnosis Handbook

1. Select
appropriate NOC outcome from Ackley/Ladwig text or from the EVOLVE Care Plan
constructor.
(You can copy and paste the information from the EVOLVE SITE
in the areas below.)

NOC outcome:

Fill out the grid with NOC indicators and the appropriate
Likert scale.
Select the appropriate point on the Likert scale to measure
the client’s current status.

Immune Hypersensitivity Response
INDICATOR
1 = not controlled
2 = slightly controlled
3 = moderately controlled
4 = well controlled
5 = very well controlled

2. Or write
outcomes to help resolve the symptoms (defining characteristics). Refer to
Section III of the Ackley/Ladwig text for the nursing diagnosis care plan or
the EVOLVE Care Plan constructor.

Outcomes:

3. Select
appropriate NIC interventions from Ackley/Ladwig text or care plan constructor.

(You can copy and paste the information from the EVOLVE SITE
in the areas below.)

NIC intervention:

4. Select
appropriate NIC activities.

Note: The Ackley/Ladwig text and the care plan constructor
gives sample NIC activities.

5. Select
interventions from the Section III care plan or the care plan constructor that
will enable the client to attain acceptable outcomes.

D. IMPLEMENT

The next step in the nursing process is to give the nursing
care utilizing the nursing interventions.

E. EVALUATE

After putting into effect the nursing interventions, the
results of the care should be evaluated by determining if the outcomes were
met. If the outcomes are acceptable, the care plan is resolved. If the outcomes
are not acceptable, further assessment should be done to answer the following
questions:

NOC Indicator
Rating at admission
Rating 30 minutes later
Rating 1 Hour later

Was the correct nursing diagnosis chosen?
Was the outcome appropriate?
Were the interventions appropriate in this situation?
What other interventions might have been helpful?

Changes in the nursing diagnosis, outcomes, and
interventions should be made as needed. This is continued use of critical
thinking to ensure appropriate nursing care.

Click here to access the Ackley, Ladwig Care Plan
Constructor to assist you in formulating your care plan. EVOLVE