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Joined: Oct 31, '10; Posts: 34 (12% Liked) ; Likes: 7

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  • Nov 16 '10

    Quote from nursingstudent_2012
    Hi. Thank you for replying. was actually a low lymph percentage. And his WBC was high. I was thinking, ahm my pt's WBC was elevated which means infection so this was reason why his lymph was low. Coz infection was the problem and lymph are responsible for immune defense. Infection is not exactly a disease right so I was thinking there was really no need for lymph cells to do their thing. Am I right?

    Don't forget about the fight flight response as all those WBC's go to fight off infection and an elevation of WBC's because of the inflammatory response alone.

  • Nov 15 '10

    Quote from nursingstudent_2012
    Can anyone please explain why a pt woth hemothorax would have a decreased lymphocytes? And for those of you who saw my earlier post, yes this is related to that.
    Skeletal Trauma: Basic Science ... - Google Books

  • Nov 15 '10

    Quote from nursingstudent_2012
    Why would the pt be on strict bed rest?
    I can think of two reasons for the bedrest. First, it can be a little difficult for a patient with a chest tube to walk around. You have an increased risk of pulling it out; although, stable patients do walk with chest tubes. Just remember the risk of pulling the tube out (and know what supplies should be by the patient at all times in case of dislodging the tube), and the risk for falling because of the tube.

    As for the second reason for bedrest, someone else above me already said it. Think about the organ you're dealing with, the lungs. If you're lung isn't working correctly, what issues might you see?

    Quote from nursingstudent_2012
    What would affect the pulse rate except meds, pain and anxiety?
    What things normally affect HR? This is true for any patient, so don't make it complicated. It may not be specific to the chest tube or Hemothorax, although it may be a contributing factor. You already listed meds, pain, and anxiety. I can think of 3 more things that may cause an increased HR in your patient. I'll give you one of them, the patient's temp. You mentioned fever in your post. Now there are two more, and they do relate to your chest tube/hemothorax. Think about what would happen if you're patient had the hemothorax and they never placed a chest tube.

    Quote from nursingstudent_2012
    Why and in what ways can incentive spirometer help a pt with hemothorax? NOTE: I have little info on this and my prof. is very adamant about having a LOT of info on each section of our careplan.
    The IS will help the patient with a hemothorax in the same way as it helps any other patient. What is the purpose of the IS? What does it do in patients after surgery, or with pneumonia? And as annoying as the IS is, it is a great piece of equipment! I've seen it really help in just a few hours of use.

    Quote from nursingstudent_2012
    How would it affect the temperature? Below is what I have about the temperature so far. Is there anything else that you could add?
    You seem to have the idea about the temp and its relation to infection. Good luck with your care plan. And thanks for coming to us with a little bit of your own suggestions.

  • Nov 15 '10

    Quote from nursingstudent_2012
    i also posted this on the students thread coz i am just really sooooo lost and am freaking out right now.

    hello everyone,
    i am writing a care plan on hemothorax. my textbooks doesn't have much information on it. i've searching the web for information that can help me but not much help either. can somebody please help me?

    temperature – as mentioned above, anxiety and pain due to trauma can cause g.d. to shiver which is a sign of chilling so the nurse should check if g.d. is shivering in order to provide necessary care if needed (lewis et al, p. 491). g.d. is also at risk for infection due to his wounds and chest tube inserted in his right chest. it’s very important for the nurse and other healthcare providers to recognize an infection on an early stage to prevent a more serious complication that it might cause my patient such as septic shock. one way for the nurse to detect an onset of infection is through an elevation of my patient’s temperature. fever is one way the body reacts to an infection. if hyperthermia occurs, a cooling blanket can be provided to help decrease my patient’s temperature. but the wound and chest tube insertion site as well as iv sites should also be inspected for redness, inflammation and yellow drainage or pus. the wound should be properly cleaned and an antibiotics should be administered to help fight off the infection. if g.d. develops sepsis, hypo or hyperthermia can occur as well as increased pulse and respiratory rate, decreased bp and decreased urine output (potter&perry, p. 500).
    in addition to checking g.d.’s core temperature, the nurse should also check my patient’s extremities especially her feet. g.d. is on strict bed rest so he would be able to stand up and walk for a couple of days.

    if g.d. has a decrease in blood supply in his extremities, his hands and feet will feel cold. this might indicate a formation of clot in his legs due to immobility. to help prevent the formation of a clot or a decrease in blood supply to his extremities, an scd can be use to help push his blood back up to his heart. also, the nurse can help my patient to do rom exercises to help with his blood flow especially when g.d.’s leg veins will not be able to pump blood back up to the heart because of lack of activity.
    let me google that for you

    in any situation don't panic..........take your own pulse first this will give you time to calm down and think.
    then consult google

    why would the pt be on strict bed rest? depending the reason for the hemothorax. the most common reason for a hemothorax is trauma to the chest. hemo--blood in the chest can be life threatening. incerasing physical activity before the traumatic bleeding has had a chance to stop can increase bleeding and cause another condition called tension hemothorax. the bedrest would be in direct coorelation to minimize activity to minimize bleeding and chance of further trauma.......and to minimize disloging the chest tube.

    what would affect the pulse rate except meds, pain and anxiety? think fluid volume as in lack there of......hypovolemia and tachycardia. hypothermia,hypovolemia and bradycardia.(very late sign) temperature for infection to name a few

    why and in what ways can incentive spirometer help a pt with hemothorax? note: i have little info on this and my prof. is very adamant about having a lot of info on each section of our careplan.

    how would it affect the temperature? below is what i have about the temperature so far. is there anything else that you could add?
    immediate trauma are at risk for hypothermia due to /in and out of hospitaland rapid iv administration

    i hope this helps........but the internet is a wealth of knowledge

  • Nov 15 '10

    I hope everyone gets a kick out of this. I just finished a refresher course and had this great instructor who worked in ER for a long time. She told us certain things should always be in our daily plan of care for a patient and if they were you could not go wrong.

    Someone else made an acronym of the points that goes like this:

    S 'n' M Excites Frank!Ha ha ha ha

    Safety, Nutrition, Maslow's, Mobility, Elimination and Fluids

    It's more like S 'n' M(squared) Excites Frank! Frank must be a pretty kinky guy! Can you tell that the nurse who made up the acronym had been a psych nurse for many years!

    Anyway, from a practical point of view with nursing, it works. It gets the patient through the shift.

    Safety is always priority, because if your patient isn't safe, then you will be writing an incident report and too many of those means you won't have a job and your patients are probably walking around with a lot of bumps and bruises.

    Mobilityis huge.
    Even if a patient is bedridden (say a stroke patient), then you better be rolling them around to make sure they have good lung expansion on both sides. (ABC's!!) Think circulation when thinking mobility also, in regard to risk for blood clots (possibly another stroke, heart attack, DVT and PE- pulmonary embolism). Circulation again - in regard to potential bed sores. You may not see the damage to tissue, because it's happening below the surface. Next thing you know, whammo - decubs! Turn, use pillow logically and use the bed booties.

    If the patient can be mobile, even up in a chair, then get them there as long as you have a doctor's order to do so. If you aren't sure because the patient just came in or they are getting weaker fast, then get that MD to order a physical therapy evaluation. Until then, have that patient turning. There are always those difficult calls, say an Alzheimer's patient who has a history of falls and is weak, but you don't want them to get weaker by keeping them in bed. The last clinical I had recently, the RN wanted the patient in a chair, so did I, the care assistant wanted a posey on that patient if they were going to be in a chair. I cringe at using restraints, but sometimes they are warranted. The doc knew the patient from the nursing home and ordered a posey while in the chair and an order for PT. Other option, get on the phone and have a family member stay with patient so they don't have to be posied. Now, you just have to see if they try to climb out of bed also and get an order for posey in bed if you have to. Ahhh! I hate restraints! It's a difficult balance, but I have to always remember that my shift is not the only shift of this patient's life. It's a collaborative effort, so do what is good for the patient now with future goals in mind. (In this case, PT).

    Nutrition is very related to strength and diagnosis.
    In the case above, you'd see how you need good calorie intake to keep a skinny little old man from becoming more weak. Then, what do you always need for old people? - If their diagnosis doesn't contraindicate it, fiber doesn't hurt to keep the bowels rumbling around. Mushed up food is not as palatable as regular food, so give it to them if they don't have any swallowing issues. (ABC's - A&B apply to people who can't eat well because of a stroke, no teeth, etc. Speech evaluation if you notice coughing. Don't want to give anyone an aspiration pneumonia!) Water is a part of nutrition that overlaps with fluids. Cleans your palate, and your mouth, prevents nasty infections in your mouth (along with teeth and gum cleaning in the morning), prevents dehydration and keeps the bowels rumbling once again! Do they need supplements. Is their neutrophil count low, (so they can't have fresh fruits, salads, and no flowers in the room because they are on reverse isolation). Do they need free H20 or juice (depending on their sodium level, are they vomiting or having diarrhea). Can they hold the fluids and food down. Do their bowels need a rest with a liquid diet (i.e, acute colitis). Do they have the gag reflex? Do we need to get their bowels woken up from anaesthesia by starting them on a clear liquid diet. If they need potassium, can you give it to them orally. If their potassium won't come up, do they need Magnesium? If they have asthma, do they respond to magnesium supplementation. How's the Calcium level? K+, magnesium and Calcium are all absorbed well in the gut. Their levels are all related and contribute to good muscle contraction and heart rhythms. Do they need low vitamin K, because they are on Coumadin. In this case, get a dietary consultation for patient teaching, give them a hand out and teach, quiz, etc. Use your common sense and learn as much about nutrition as it applies to the particular diagnosis. You will learn a lot here and it very much relates to fluids (riders and electrolyte balance).

    Maslow's always needs to be included. You need to see what level your patiet is at and then get to that level with them so you understand how you will communicate with them, give them what they need and do your teaching appropriately.

    Elimination is very related to mobility and nutrition and fluids.
    How are they going to get to the bathroom? and getting there safely?, or do they need that commode or a bedpan. Think logistics and need for mobility tempered with safety and reality. They are not going to be in the hospital forever!
    Are they eating enough to even make a bowel movement? (I hope so, if not, then that is the goal). Do they have enough fiber, oral fluids and mobility to keep them regular? Do they have a history of bowel obstructions? Look at their baseline, complications, patterns of output and goals.
    Are they post-surgical. If so, do they have bowel sounds, gas, cramping? Have they urinated?, Is the suprapubic area hard, distended? Do they need to be straight-cathed to see if their kidneys are making urine output? Do they need fluids, are they 3rd spacing?
    ** I have learned how important 24 summaries of I's & 0's are! Review them. Learn their importance. This is a primary nursing responsibility. You are the first person to notice changes and should try to recognize situations where I&O problems are apt to happen so if they do, the problem gets moved on right away. It never hurts to have a doc review this if in doubt. You'll end up learning more when you ask the questions also. ***

    Do you see how this all has moved very to Fluids?
    - - -OK, be aware, I went off on this subject. Stick to the basics. Fluids are complex. It's good to poke your head in books, talk to the nephrologist, talk to the cardiologist, read about endocrinology. This is the cellular level of nursing and medicine, but there are also some basics to always remember and that's what goes into your care plans. Always know why they are getting fluid and why THAT PARTICULAR TYPE OF FLUID. Ask the doc if you can't figure it out. No use beating your head against the wall, right? We are here to learn and no one is a brainiac 24/7.

    The part about care partners will not affect you until you start working. The stuff about SIADH, try to learn it at some point. The inter-relation between the endocrine system and fluids is very interesting and really comes into play in cancer and post-op patients. Learn about antidiuretic hormone at some point and understand its importance in fluid balance.)

    Fluids include ORAL, G-tube, NG-tube, intravenous, intra-arterial, intraosseus, intrathecal.

    Per my Med-Surg book, 2002 Ignatavicius and Workman, Med/Surg Nursing, Critical Thinking for Collaborative Care. . "These solutions and medications may be adminstered for therapeutic or diagnostic purposed, including the following:

    - replacement of fluid, electrolye, and nutrient losses
    - adminstration of anti-infectives
    - blood and blood product transfusions
    - administration of enjancing agents for diagnostic imaging

    My notes from class say are more general:
    1. Maintenance/ of daily fluid requirements
    Learn the difference between crystalloids and colloids. Understand what isotonic, hypertonic and hypotonic is in terms of osmolality comparted to the osmolality of plasma.
    Memorize what kinds of fluids are isotonic, hypertonic and hypotonic.
    Begin to understand what fluids are used in what situations (chronic and acute situations) and learn why.
    Learn the different blood parts/products, when they are used and why they are used.
    2. Replacement/ of loss of fluids - drains, insenisble loss, diarrhea, wounds, bleeding.
    3. Treatment - used as a medium to deliver therapy, e.g. (K+, antibiotic, hyperalimentation.)
    4. Diagnosis - used as a medium to deliver diagnostic dyes
    5. Palliation - used as a medium to deliver pain medication, nutrition.

    Do the 24 hour review of fluids. It is every nursing shift's responsibility. . Do not getting the habit of slacking in this area. Too many things are missed due to this and they can be things that are critical. If things look imbalanced, investigate why and ask yourself if the problem is being addressed. If it is not, then do what you can to correct a problem and/or notify a doc for further evaluation.

    Just remember to think of what a typical patient that has same diagnosis would look like. If you don't know that, now is your time to find out, so look in your med/surg book. Then make sure your care plan addresses whether or not the patient is "balanced" fluid-wise or not. If yes, then you can always write done "potential for fluid and electrolyte imbalance" if that is a common problem for this type of patient. Then you just write - monitor labs results for electrolyte abnormalities and monitor I & 0's for imbalances (over or underhydrated), or you can write "take off orders for blood draws to monitor fluid and electrolyte status and make sure they get drawn and lab gives me a result. Report abnormalites, institute oral or IV therapy as appropriate or as ordered." Then or course, give everyway you can do it orally before resorting to IV if oral is not contraindicated.

    Here are some typical I & O situations:

    Think about who is at risk for dehydration and why? Think about who is at risk for a fluid overload and why? Is the Na+ level high or low. If they are dehydrated, is it because they are putting out too much fluid or have diarrhea, or because they are not taking in enough fluid.

    Their mental status and energy level is very affected by fluids. When was the last time you were hot and didn't drink water regularly for a few days. Did you feel like doing jumping jacks, doubtful.

    If they are post-surgical, watch for adequate urine output and mental status changes. **Learn the dangers of D5W post-surgery and in general, how it can contribute to cellular swelling and increase intracranial pressure. Read some cases studies on this.**

    Is there some kind of problem that affects them in which they cannot eat or drink (mental or phyical problem)? If so, when are the fluids going up. Watch the K+, Ca+ and Mag+ levels. Always remember that K+ is a drug - too much can make your heart stop. If a K+ rider is needed, best given through a large vein with a small gauge IV catheter to prevent pain at the IV site. If lidocaine is added, realize it can mask pain, so watch that IV site. Lidocaine is a drug too. Become aware of it's affects. If K+ needs to be given, can you do it orally or through a G-tube rather than through an IV. If the K+ level will no come up, get a Magnesium level. (K+ will not come up if Mag is too low). When will this happen? In patients with lots of watery diarrhea. Get a fecal incontinence bag on those patients. You need to know how much fluid they are losing in order to replace what they are losing AND give them their daily requirements.

    Look at the output. Is it "sick" looking?
    Diarrhea, bloody stool, steattorhea, solid as a rock, C. diff green and smelly, yuk.
    Urine - is there enough? Is it smelly, is it concentrated? Does it have while blood cells in it? Is my patient eating any fruit (water content?), drinking, do they have good peri-care if that foley is in. If they have a suprapubic, is the site red, tender, distended? Is my patient so big, peri-care is difficult? If so, get however many it takes. Do they have to have that foley? Does my patient have a fever? Are they losing fluid in sweat, insensible losses. Do they need replacement fluid on top of that?

    Lungs - does my patient have CHF? are they coughing? Do they have crackles or rhonchi? Make them cough. Does upper airway congestion clear? Does the crackling clear? Do they need some Lasix. Are they edemetous? Are they on fluids and getting overloaded?

    These are the extras:
    ----- If a care tech isn't getting it done, tell them it is imparitive for care. Is this a problem for all the nurses? If so, maybe all the nurses need to bring this up at a meeting. If it's just one care tech for everyone, let the super know. If it's just that care tech with you, let them know that your nursing care needs to look good, if they are not being responsible and in doing so, make you look bad to the docs and your supervisor, let them know you're going to have to say something to someone because you can't put your job on the line. (You can't let negligence to duty go and letting it go makes you negligent and on the hook for it). If there is a legitimate excuse or you can estimate output, put something down rather than nothing, but put the reason why it is not exact. (Used the toilet before hat was given. Pt. took hat out of toilet.). Try to write down the number of voids at least. But don't completely guess at cc's and never make up anything! Let the next shift know exact I&O's weren't obtained and that you have told your partner you need exacts now. Write an order for strict I & O's if you can. Get a doctor to order it. Get those I's and O's going. always, if you empty something, record what you emptied and communicate it to the partner somehow, flowsheet is the best way. So many patients need I's and O's and considering how sick most patient's are, it's unusual, in my book to see someone who doesn't need them. (At least on a med/surg floor). The patient didn't just come in with nothing going on. If they were well enough, they'd be at home or somewhere else. If they can't be somewhere else, then things are out of whack.

    **Learn about SIADH** Syndrome of Innappropriate ADH, watch for low Na+ levels. It is complicated, so take some time to undestand it and read some case studies. I had a patient with this and then his mental status went bad. He was taking Ambien at night, so I thought he was just tired in the morning, thought I'd let him wait to do that wash up. Nope, bad idea. He was actually becoming somnolent. When someone is falling asleep right in front of you mid-sentence, it's a problem. EKG showed heart block, we sent him to telemetry. By the way, his foley looked like a Mai Tai with Oxi-clean in it!) This guy had been on a fluid restriction the night before and had a 250cc bag of 3% saline up over the day prior. Not .3%, 3.0%. In the morning, I did notice that no one had taken the water pitcher out of his room. (That should have been a clue to me right away that the care was not on track. When I asked him about his fluid restriction, he told me no one had told me about it. Here's another clue.). This guy was a confabulater. He would tell me anything to make things seem OK and was not concerned about anything despite the fact that he had been in the hospital for days, hadn't eaten well for awhile and had cancer. Hmmm... something was wrong here. Yes... it was his mental status. Sometimes it's hard to get a grip on. When in doubt, ask your peers, a more senior nurse who has time to help, if not available, a supervisor, if not available, a doc. What did the nurse who gave you report say? Read the chart, when in doubt, call the doc. Sometimes you don't have time to figure things out on your own. Call the doc. Make sure you have an assessment to report before calling and let them know that you aren't sure if this is their baseline if that mental status has changed. Better safe than sorry. You do work for the patient, remember that. This guys was starting to have mental status changes due to cellular swelling in his brain. Yikes, that's a situation that deserves a monitors if not the ICU.

    Remember, I'm a nurse with just 3 years of experience, or just 3 years of experience, however you want to look at it.

    Geez - I better get off my butt and start working on my resume and looking for a job, eh?

    Good luck. Hope I was helpful. (and not confusing. Things come with time. Just learn it as it applies for your care plans. Learn it like a lecture/class when you are in class and studying for tests.


  • Nov 15 '10

    Quote from ~Tinkerbell~
    I am a new nursing student and am having difficulty constructing a care plan for my patient. I need one long term goal and two short term goals w/ interventions. I am at a loss as to were to begin. My patient was admitted for kidney stones, UTI, and flank plain. I am having difficulty formulating and prioritizing nursing diagnosis due to his medical history which includes:
    1. CKD stage II with baseline creatine of 1.2
    2. Diabetes
    3. Hypertension
    4. Kappa restricted multiple myeloma associated with HIV
    5. HIV on HAART therapy
    6. History of kidney stones
    I cant seem to get past this point to even start my care plan. He was scheduled to be discharged to a rehab facility the day after I saw him.

    Any help and guidance you can give me would be appreciated. THANK YOU!!!
    I believe you're thinking too hard on this one.

    Three ADM D(x)'s were UTI, Flank Pain and Renal Calculi. So work with those if they're still present.
    Infection, Pain and Ineffective Health Maintenance respectively.

    Two short term goals will deal with the pain and UTI. The long term goal will include dietary teaching to prevent stones.

  • Nov 1 '10

    There are days when I wonder why I ever left computers; usually, that day is payday. I make a little more than half of what I used to. And there are times when I feel like I should just record "I can't afford it" and put it on automatic replay. My life seems to have become an endless list of things I can't afford to do. It was payday, and I was grumpy.

    I admitted a new patient, and she was truly sick....her heart was trying to stop, (when a patient bradys down to 28, I become tachycardic for them). Luckily, the cardiologist was there and he got a temporary external pacemaker in place in record time. Her heart rate stabilized due to the forced beats, and we all took a cautiously deep breath. We got rid of the bloody sheets, drapes, etc., and tidied her up so the family could come in. The cardiologist is discussing next steps with the doc on for medical management and the patient's adult children.

    Among the family members was a cute little 5 year old. She's scared of all the ICU "stuff" and cowering behind her mom. A scared kid always breaks my heart, and I take a minute and show her the "TV" on the side of the bed, let her watch me weigh the pt, show how it can move the bed (unfortunately, it doesn't have the "Murphy bed" or "hideaway bed sandwich" option we all keep asking for). She looks up at me and says, "My nanny is my bestest friend." I look down, and say, "mine was, too."

    In reality, mine wasn't...a alcoholic valium junkie doesn't love anything but the next yellow pill, but this little one apparently has the relationship I always wished for. Her eyes are huge, and she's trying to be so grown up. "Is her heart better? Is it still broke?"

    I squat down so we're eye to eye and tell her that we've got something helping her Nanny's heart so it's not so broke, but that we'll get someone to fix what's broke in the morning. "Like a mechanic?" I look over at the cardiologist who's grinning at me, and say, "Yes, but he's a very special mechanic, and he only works on hearts, not cars." She seemed to think this over, and I went back to work, with my little helper shadowing my every move, and watching what I'm doing to "Nanny" like a little hawk.

    About 20 minutes later, they are getting ready to leave and I'm in the nurse's station, getting a list of instructions from the cardiologist on how he wants the night handled, when suddenly this little blond streak comes tearing into nurse's station, and the little girl throws her arms around my legs and hugs me. "Thank you for looking after my Nanny." The mom is giving chase and apologizing, and we get the little one into her arms and out the door. I go back to the doc and watch the small blond head, firmly pressed against her mom's neck, disappear on the other side of our big double doors. I hope she's not crying, but I think she is.

    I looked down at the cardiologist, and said, "You, know, I don't know how much you make a day, Doc. But today, I made more that you did. I got paid with a hug."

  • Oct 31 '10

    A burn causes cellular damage leading to an inflammatory response, which increases capillary permeability, which leads to a fluid shift from the intravascular space to the third spacing, which leads to a dehydration condition. Dehydration lowers BP, which decreases cardiac output, which decreases tissue perfusion throughout the body. Dehydration can be averted by initiating fluid resuscitation, which typically is done with LR, not NS, though. How much fluid is given is individually calculated. The Parland formula I was taught was 4 mL/kg multiplied by the burn surface area (BSA). I believe the most common method of calculating a BSA for an adult is the "Rule of Nines" and for children the Lund-Browder chart. Then of this amount is given within 8 hours of the injury, the next 8 hours, and the last the next 8 hours. Fluid administered after this 24 hours is less predictable.

    As missbutton stated, saline lock just means that an IV cath is in place for IV access, if or when that access is needed.