Nursing Diagnoses | Specifications | Aim | Nursing Interventions | Evaluation |
Deficient Fluid Volume: Fluid loss due to loss of appetite, malnutrition and diarrhea | Poor oral intake, dryness of skin and mucous membranes, loss of body weight | Regulation of fluid intake in accordance with age and metabolic requirements. Regulation of signs and symptoms of dehydration. | - Intake and output was monitored. Noted incerased and decreased urinary output. - Infusion rate of parenteral fluids was monitored closely. - The patient was weighed daily. - Vital signs was monitored regularly. - Hydration and dehydration status were evaluated (fontanelle, mucous membrane, skin turgor, tears). - Laboratory findings and blood gas tests were checked. | The signs of dehydration tend to decrease, the oral mucous membrane is slightly moist. |
Impaired Oral Mucous Membrane: Due to lack of fluid volume, common oral candida albicans, decayed teeth and O2 support with reservoir mask. | Dryness and redness of the oral mucosa, common oral candida albicans | Ensuring the integrity and moistness of the oral mucosa. | - The infant’s oral mucous membrane was evaluated daily. - Redness in the mouth and sores on the tongue, tissue integrity, moistness were observed. - Moisturizers were applied to the rim and lips to prevent chapping and drying. - Oral care was applied with sodium bicarbonate diluted with physiological saline solution every six hours. - Mikostatin was administered as ordered by the doctor. - The mother was informed about oral care and its importance. - The child was hydrated. | There is still oral candida albicans and mild redness. The situation continues. |
Imbalanced Nutrition: Less Than Body Requirements: Associated with anorexia and oral candida albicans | Losing weight, eating less than the recommended daily amount and switching to parenteral nutrition | Reaching the ideal nutritional level. | - The child was weighed every morning at the same time and in the same clothes. - Intake and output was monitored. Noted incerased and decreased urinary output. - Head circumference, height and weight percentile values were followed and recorded. - The child underwent central venous catheterization and TPN was started. - In addition, Peptamer food was added to the diet. - The amount of food given was recorded regularly. - Laboratory results were followed. | TPN and parenteral nutrition were discontinued on the 35th day of hospitalization. She continues to be fed with Peptamer formula. |
Delayed Growth And Development: Immunodeficiency associated with adrenal insufficiency | Body weight and height below the expected percentile (height, body weight and head circumference below the 3% percentile) | Ensuring the child’s age-appropriate growth and development. | - A nutrition plan was created according to the needs of the child. - Height, body weight and percentile values were checked at regularly. - Its care is planned in the same time period. Frequent rest periods were planned. | Height, body weight and head circumference are below the 3% percentile. There is developmental delay. The child does not grow and develop in accordance with his age. |
İmpaired Tissue (Skin) İntegrity: Because of edema, phimosis operation and invasive procedures | Damaged skin surface | Protection of skin integrity. | - Central venous catheter site and operation area were checked daily and wound care was performed. - The probe was changed every 3 - 6 hours when the patient had a vital monitor probe. - Unnecessary invasive intervention is avoided. - The position of the child was changed every 6 hours. | The patient does not have erythema or redness that disrupts skin integrity. |
Fear: Due to the effort to cope with the rare and incurable disease, lack of knowledge, the abundance of painful interventions and prolonged hospitalization. | Child cries during treatments or sees healthcare worker and parent seems nervous | Ensuring the child’s adaptation to the healthcare worker and the hospital environment. Informing parents and supporting their participation in their child’s care. | - A calm and safe environment was provided for the child and family. - Parent was informed before all procedures. - It was ensured that the parent was with the child during the procedure. - It was tried to ensure that the child was taken care of by the same nurse as much as possible. - It is ensured that the child’s favorite toys are with him. - Parents were encouraged to voice their fears and concerns. | The child’s crying time during interventions decreased. It has been observed that the family trusts the health workers and exhibits more adaptive behaviors. |
Diarrhea | Frequent (at least 3 times a day), watery and misshapen stools, increased intestinal sounds, continued antibiotic therapy | Normal consistency and number of stools. | - The child underwent central venous catheterization and TPN was started. In addition, Peptamer was added to the diet. - The amount of food given was recorded regularly. - Probiotic and Zinco syrup added to the treatment. - The child was hydrated. - The child was weighed every morning at the same time and in the same clothes. - Hydration and dehydration status were evaluated (fontanelle, mucous membrane, skin turgor, teardrop). - Laboratory findings and blood gas tests were checked regularly. | Diarrhea continues. |
Acute Pain: Because of the painful procedures such as CVP and IV catheter insertion, endoscopy, colonoscopy, and diarrhea | Score of visual pain scale is 3, anxious look and groaning | To reduce or eliminate existing pain. | - Vital signs were checked regularly - Pain was evaluated with visual analog scale (VAS) and recorded. - Nonverbal pain behaviors were observed in the child. - Pain was tried to be reduced by using therapeutic techniques such as distracting the child’s attention and keeping favorite toys with him. - When necessary, analgesics were administered. | The child’s vital signs are stable. VAS pain score was evaluated as 2. The child continues to look anxious but there is no groaning. |
Fatigue: Because of the immunodeficiency, adrenal insufficiency and hospitalization and persistent diarrhea | Weakness, constant fatigue, hypotonia, inability to walk | Relieving fatigue. | - The amount of light, heat and sound of the environment has been adjusted. - Unnecessary invasive procedures were avoided. - Interventions were planned to provide resting periods for the child. | Weakness, fatigue, hypotonia continues in the child. |
Risk for Secondary Infection: Associated with presence of central venous catheter, gland dermatitis, surgical operation and prolonged hospitalization | CRP: 23 mg/dl (<0.5%) | Preventing the child from having a secondary infection other than the current infection. | - He was checked in terms of signs and symptoms (fever, chills, local or general skin discoloration) that may develop due to infection. - Hands were washed before and after each contact with the patient. Aseptic technique rules were followed in all invasive procedures. - Visitor restriction applied. - The family was informed about daily hygiene and diaper dermatitis. - Unnecessary invasive procedures were avoided. - The patient was started on topical treatment due to diaper dermatitis. (gentian violet) | The child has an infection. Intravenous antibiotic therapy is administered. No secondary infection was observed in the patient.CRP: 8.88 mg/dl (<0.5%) |
Risk For Bleeding: INR: 1.33 and decrease in platelet level | Risky value of laboratory tests showing signs of bleeding | Absence of signs and symptoms of bleeding. | - Bleeding signs and symptoms were checked. - Vital signs were measured at regular intervals. - Laboratory findings were checked for Pt, Aptt, Inr and platelet count. Platelet transfusion was performed according to the results. - Unnecessary invasive procedures were avoided and the interventions were done gently. - The patient was protected against bumps and falls. - The caregiver parents were informed about the symptoms of bleeding and ways to protect themselves. - Kvit was applied at the order of the physician. | No signs of bleeding were observed in the child. |
Risk of electrolyte ımbalances: Associated with resistant diarrhea and malnutrition | Caused by resistant diarrhea and malnutrition | Fluid electrolyte values have to be within normal limits, fluid intake and output have to be in balance | - Vital signs were checked regularly. - The daily fluid balance was checked. - Serum electrolyte levels were checked regularly. | For now the fluid intake and output are in balance. |