squishy11 1,543 Views
Joined: May 6, '09;
Posts: 27 (4% Liked)
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Thank you SO much for your reply. You have really helped me. Last semester we didnt have to do a care plan so I kind of forgot about the diagnosis that are not strictly related to the illness.. such as pain, constipation, fall precautions due to the meds... etc... you have helped me to have a more overall view of the patient. So thank you so much!! I appreicate your help. I really do!!!
So I am in my last year of nursing school. Hooray . Anyway - I have care plans down pretty well. However, my problem is that my pediatric patient I am doing a careplan on is pretty healthy. The reason for her admission was an infection in her earlobe. (Piercing of cartilage gone REAL bad) .
I am having trouble because I need to come up with 10 diagnosis! I just can't do it.
Everything was normal on her. Except for the obvious infection of her ear. She was on Vanco and Percocet. She is 12 years old. When I saw her she was going to be scheduled for an MRI as well as surgery to drain the ear. (which she ended up having but when she was still there a week later she was no longer my patient). Most of her care happened after I saw her because she had just been admitted that morning.
Any ideas for diagnosis that I can use?
Other then that - there is much to this case. (That I can see)
I would obviously use infection , knowledge deficit, and disturbed body image ... perhaps?
Thank you for your help ... The care plan is due the 13th, and we will get it back the following week .. I will let you know what I have come up with and how it went
Hi all.. I jsut wanted to check to see if my list of diagnosis are in the correct priority. I am a little confused because in my last semester I was told that a "RISK" diagnosis NEVER comes bfore and actual.. but I have seen some risks diagnosis come beofre actuals in a few different books. So now I am a bit confused... can anyone let me know if this list looks like it is in the correct order?
1) ineffective airway clearance r/t retention of secretions AEB non productive cough
2)ineffective breathing pattern r/t respiratory muscle fatigue AEB shortness of breath
3)Impaired gas exchange r/t ventilation-perfusion AEB hypoxemia
4)Imaired cardiopulmonary tissue perfusion r/t decreased hemoglobin in blood AEB dyspnea (or could I write AEB decreased hemoglobin level on lab?)
5)Impaired physical mnobility r/t lower limb weakness AEB pt states legs feel weak when standing
6)Activity intolerance r/t imbalances betqween oxygen supply and demand ARB exertional discomfort (also.. is this the same as the cariopulmonary?)
7)Acute pain r/t inflammation of lung tissue AEB pain is a 6 on a scale of 1-10
8)Risk for deficient fluid volume r/t diarrhea
9)Risk for falls r/t generalized muscle weakness
10)Risk for injury r/t altered clotting factors
Thanks for any help in advance... I have 5 of these written up, but I am worried about the priority... Like I said - I was told that the RISKS always go last -- but it seems like a Risk for deficient fluid volume should be a little higher in the list...
Thanks again all.. and Happy Nursing!
I am in Med Surg, and am finding that on the tests (real ones and practice ones) I ALWAYS get the right answers down to 2. And more then half of the time I pick the wrong one. Obviously, my critical thinking needs some help. I have purchased a couple of books in addition to the med surg book that I had to buy for my class. Can anyone suggest a couple of good books that will help my process of critical thinking...? Perhaps something that has rationales for correct answers. My problem is that I seem to pick the answer that you would do second. Never the one that you need to do first. So I am obviously missing something. I would like to improve my grade from my last test, as well as develop my critical thinking... (I am assuming and hoping that critical thinking is something that evolves over time... ) .... Any suggesitons would be very helpful!
Thanks everyone and have a great day!
thanks for the advice. I am guessing a lot of my classmates maybe put too much into it. So I have it written, and we shall see how it goes. It was shorter then my classmates, but is right to the point. I started at the head, and went down to the toes..
Kinda of nice tho, my last instructor just wanted SOAP notes, and those, I can do in my sleep now... so I am hoping narratives will become my friend the more I do them
Life.. what life?? LOL... I am a nursing student in my 30's though, and trust me, I wish I had done this when I was 18....
It's tough, but if you manage time well, and really enjoy what you are doing then you will be fine... Ya know the saying what doesnt kill you makes you stronger? I am only in my second semester, but I think that saying was made for nursing school!
Good luck !!
Hi all, I got a tremendous amount of help here my last semester, so I am back . I have a pt and our care plan is of course supposed to be more involved I suppose then last semesters.. I just wanted to know if these diagnosis look ok... I am not sure if you are allowed to include lab numbers in your diagnosis or not.. Here is some info about my client that I thought would be relevent. 80 yr old with pneumonia her h&h are low her bun and creatnine are high (still trying to figure out what that means to her system as a whole.. know its the kidneys.. thinking a volume prob?) umm and everything else is ok cept her glucose is 137.. Can someone just let me know if these diagnosis make sense... I am pretty confident they do.. here they are in no particular order
ineffective airway clearance rt/ retained secretions AEB nonproductive cough
impaired gas exchange r/t ventilation-perfusion imbalance AEB tachycadia
deficient fluid volume r/t active fluid volume loss AEB diarrhea
acute pain r/t inflammation of lung tissue AEB pt's report of pain at a 6 on a scale of 1-10
deficient knowledge of pneumonia and treatment r/t lack of information AEB pt states "this is the first time I have had pneumonia"
risf for infection r/t hospitalization.
risk for injury r/t altered clotting factors (she is on coumadin)
imbalance nutrition : less then body requirements r/t illness AEB pts consumption of less then 50% of her meals
(that one I am not sure about... dont know if I can blame it on the illness.. she just told me she doesnt like hospital food)
hyperthermia r/t illness ARB increase in body temp above normal range
Ineffective cardiopulmonary tissue perfusion r/t hemoglobin in blood AEB dyspnea and low hemoglobin level of 9.3.
I am sure there are many more that I can use. We need to write 10 and choose 5 to write up. I had a patient last semester with Pneumonia as well that I had to write up 3 on.. so I am trying to expand my horizions and use totally different diagnosis so as not to right up the same ones. Any thoughts on these? good..? bad?.... any help would be appreciated! :heartbeat
Just looking for a little help... I made it through my first semester with flying colors, however now I am in Med Surg. I felt I was doind well and getting the concepts, but then.... our first test.. sigh... I did pass with a 76 (passing is a C in our program) , and 50% of the students were below a 66. So I am not sure how I feel about this...
Anyhow... I have to write a narrative note (which is my worst enemy at this point.. still) on my patient who has pneumonia -- a few people have handed in notes already, and were reamed for having 'too much info' on them. And I think that is because we are also in Health Assessment.. and that instructor wants about a page of assesments on each system.... so.. my quesiton is this -- how do I write a narrative note for an elderly woman who was admitted for pneumonia... ?
Can I just get a wording check? I have some diagnosis... and they are coming from the info I gathered from my pt. I know you cant tell me if they are appropriate to the patient, but is the wording OK for a priority list...?
1) Ineffective airway clearance r/t excessive mucous AEB inability to cough effectively.
2) Impaired skin integrity r/t tissue breakdown AEB redness on sacral area.
3) Impaired physical mobility r/t impaired balance AEB limited muscle strength in lower extremities, pt states “my legs feel very weak when I stand”.
4) Activity intolerance r/t generalized weakness AEB pt states “I feel very weak all the time and don’t get out of bed much”.
5) Risk for deficient fluid volume r/t diarrhea.
6) Risk for falls r/t diminished mental status.
7) Risk for infection r/t IV lock.
thanks again! (slow day at work )
Another question ... could I have Risk for infection r/t IV lock... or would I have to add more into that?
Daytonite, I would like to officially hire you as my nursing care plan tutor! I really can't tell you how awesome you are, and how thankful I am to be a part of this message board!
Have a great holiday... and I am truly thankful for you!
Ok, I see what your saying.. I dont have my plan in front of me... but I know I wanted to incorporate dementia into it... so I suppose a more appropriate dx would be impaired physical mobility r/t impaired balance AEB limited muscle strength in lower extremeties, pt states "My legs feel very weak when I stand".
Thanks Daytonite, as I have said, you really helped me get thru my last 2 plans, and for some reason the task seems a little more daunting now because I have 3 to write up.. I don't understand it.. I did very well on the first two.. it's strange.. I almost feel more lost this time which is crazy becuase I have my first two to go off of. (Altho these 3 include meds...)
I just have a quick question. I asked my professor this question, and she did not give me a satisfactory answer. I have a patient with dementia and was wondering if I could use the word dementia in my dx. I see in my care plan book that it is listed as r/t factors as well as AEB. My instructor said that it is a medical diagnosis and I shouldnt use it but if it is in the book its ok to use it.. (she often says things like this and then will mark everything wrong when you do as she tells you..) ... I was looking to go the route of something like impaired physical mobility r/t dementia aeb altered mental status.... (havent finalized yet)... but the word dementia scares me since it is medical...
This letter is for Dayonite....
I wanted to THANK you for all of your help with my initial care plan. I was SO confused and didn't want to end up with info that didn't make sense, follow the process etc... I just got my firt 2 care plans back on my pt and wanted to let you know I got a 32/32 and was told that the professor was impressed with my care plans and that I showed great critical thinking and my plans were beyond a novice nurse's level.
I attribitute this to your help! THANK YOU SO MUCH!
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