Latest Comments by cld1217

cld1217 943 Views

Joined Apr 28, '10. Posts: 7 (14% Liked) Likes: 3

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    I remember seeing on the chart that he had pain 0/10 the past few days, so i didn't see that as a current issue. However, i am not sure if disturbed body image is or not. He has a hx of depression, although, i figured other diagnoses were higher priority than emotional stability?

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    Thank you so much! I confirmed after reading your comment that i did not get enough information at the hospital when i went. i didn't look at I&O. i didn't record VS. The only thing i remember now, is that he had a pain of 0/10 for the past few days, so i knew pain wasn't a current factor. But you definitely helped fill in some blanks for me. We have a graphic analysis for our nursing diagnoses and it only has 4 spots, but your right, i could do more.

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    Case:
    -Med Dx- Colovesical fistula (post low anterior resection for rectal cancer) i.e. hole between colon and bladder
    -partial/end colostomy performed
    -PICC; NPO, Feeding tube c enteral feeding cont 24h & free h20 q4h; 2L NC
    -LESIONS: pressure ulcers (L heel, coccyx) & L/midline abdomen & L LE wounds (c wound vac)
    -LABS:

    • INCREASED (na, chloride, glucose, BUN, creatinine, Alk ph, CK total/MB, total bili, PT, pH, WBC count, Neutrophils, urine (blood, protein, urobilinogen, nitrites, leukoctyes, bacteria)
    • DECREASED (O2 sat without NC, PCO2, Ca, total protein, albumin, prealbumin, INR, RBC, Hgb, Hct)

    NEED:
    TOP 4 nursing diagnoses; Possible options?:

    1. Risk for infection R/T recent invasive prodecure, multiple skin lesion, bacteria in urin, and increased WBC count.
    2. Risk for deficient fluid volume R/T deviations affecting fluid absorption, hypermetabolic state increasing fluid needs, and increased wound drainage
    3. Impaired skin integrity ....
    4. Risk for ineffective gastrointestinal tissue perfusion ..... ?
    5. Imbalanced nutrition: less than body requirements R/T high metabolic needs, decreased ability to ingest/digest food ??
    6. Ineffective breathing pattern ...?
    7. Risk for dysfunctional GI motility R/T abdominal surgery, immobility ??

    I don't feel very confident about these, and could use some advice/suggestions (since this is due tomorrow morning)! I am struggling with prioritization too!
    Thank you :-)

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    I am agnostic and nursing student. This topic always makes me feel uncomfortable. I'm nervous that in the future I will be put in awkward religious situations and not know what to say or do, because I usually just avoid talking about it since people usually think your the devil, or tell you that you are going to go to hell (my mother-in-law and step-mom told me that). My dad doesn't even know, because hes all about being Catholic, tried to raise me that way. Props to everyone who has a similiar situation, because i know it can be difficult most the time :-)

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    For some reason it is hard for me to prioritize the diagnoses. i know it goes ABC's then Pain, but when your pt doesn't have problems with any of those things, then i get stuck. And now i'm wishing i would have gotten more information on my pt before i left the hospital i.e. on his breathing, etc. to see if i can even use "Ineffective breathing pattern", because all i know is that he is on 2L NC becuase his O2 sat was a little low. BLAH. Sometimes this is just frustrating.

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    Case:
    -Med Dx- Colovesical fistula (post low anterior resection for rectal cancer)
    -partial/end colostomy performed
    -PICC; NPO, Feeding tube c enteral feeding cont 24h & free h20 q4h; 2L NC
    -LESIONS: pressure ulcers (L heel, coccyx) & L/midline abdomen & L LE wounds (c wound vac)
    -LABS:

    • INCREASED (na, chloride, glucose, BUN, creatinine, Alk ph, CK total/MB, total bili, PT, pH, WBC count, Neutrophils, urine (blood, protein, urobilinogen, nitrites, leukoctyes, bacteria)
    • DECREASED (O2 sat without NC, PCO2, Ca, total protein, albumin, prealbumin, INR, RBC, Hgb, Hct)

    NEED:
    TOP 4 nursing diagnoses; Possible options?:

    1. Risk for infection R/T recent invasive prodecure, multiple skin lesion, bacteria in urin, and increased WBC count.
    2. Risk for deficient fluid volume R/T deviations affecting fluid absorption, hypermetabolic state increasing fluid needs, and increased wound drainage
    3. Impaired skin integrity ....
    4. Risk for ineffective gastrointestinal tissue perfusion ..... ?
    5. Imbalanced nutrition: less than body requirements ... ??
    6. Ineffective breathing pattern ...?
    7. Risk for dysfunctional GI motility ...?

    I don't feel very confident about these, and could use some advice/suggestions!
    Thank you :-)



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