HELP

  1. 0
    I am extremely frustrated that we are to create a plan of care without any assessment data.

    The labs and H&P simply dont give enough info to come up with

    3 actual

    2 risks

    1 readiness.


    Please Help. I have elevated WBC. congestion. SOB. Elevated glucose. CT shows atelectasis. O2 is super normal @ 99% breaths are 20.
    pt is none smoker.

    Diagnosis is: chronic bronchitis and COPD.

    I have NO assessments to make a proper cp... what do I do? I often can wing it somehow but ... especially to those instructors ... please advice me on what to do.
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  3. 4 Comments so far...

  4. 0
    unstable glucose levels could be one
  5. 1
    Ineffective airway clearance
    turnforthenurseRN likes this.
  6. 1
    Risk for activity intolerance

    Impaired gas exchange r/t lung volume reduction
    turnforthenurseRN likes this.
  7. 0
    Quote from FatKittyHenry
    I am extremely frustrated that we are to create a plan of care without any assessment data.

    The labs and H&P simply dont give enough info to come up with

    3 actual
    2 risks
    1 readiness.

    Please Help. I have elevated WBC. congestion. SOB. Elevated glucose. CT shows atelectasis. O2 is super normal @ 99% breaths are 20.
    pt is non smoker.

    Diagnosis is: chronic bronchitis and COPD.

    I have NO assessments to make a proper cp... what do I do? I often can wing it somehow but ... especially to those instructors ... please advice me on what to do.
    If you have the H&P what was the chief complaint of this patient? Do you know what meds they are on?

    What does this information tell you.....
    WBC. congestion. SOB. Elevated glucose. CT shows atelectasis. O2 is super normal @ 99% breaths are 20.
    pt is none smoker.

    Diagnosis is: chronic bronchitis and COPD.
    You know that the patient has COPD....What is COPD? What does it do to the patient? What would help the patient? What is atelectasis? (Atelectasis is the collapse of part or (much less commonly) all of a lung. Symptoms: Breathing difficulty; Chest pain; Cough; Fever, low-grade, usually after surgery). What symptoms does this cause? What can you do to help this patient?

    You know you have and elevated blood sugar.....what could happen with an elevated glucose? IS this a trend or could this be a random glucose done after a candy bar....so they would have a Risk for unstable blood Glucose level .....right?

    They are short of breath.....what does being SOB do to a patient...what would this patient need? They could have an Activity intolerance, Ineffective Airway clearance, Ineffective Breathing pattern or an Impaired Gas exchange...right?

    Although they have an elevated WBC......they could be at risk for infection with the chronic nature of the bronchitis and COPD.

    Look at what your CI gave you.


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