the young, without pre-existing disease, will compensate with their spo2 a long time. when that is compromised with a critical value you have missed something and are in serious trouble.
think about the pain. think about ineffective breathing patterns becasue of the splinting from the rib fractures is the patient deep breathig enough? willl this place them at risk for pneumonia? look up flail chest. look up epidural and side effects and narcotics and side effects. how many days post trauma? is the patient adequately hydrated? is there a skin integrity issue? any abrasions?
you need to know the pathophysiology of your disease process. you need to assess your patient, collect data then find a diagnosis. let the patient data drive the diagnosis. what is your assessment?
the medical diagnosis is the disease itself. it is what the patient has
not necessarily what the patient needs.
the nursing diagnosis is what are you
going to do
about it, what are you going to look
for, and what do you need to do/look for first.
care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. it is trying to teach you how to think like a nurse. think of them as a recipe to caring for your patient. your plan of how you are going to care for them.
make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first. here are the steps of the nursing process and what you should be doing in each step when you are doing a written care
- assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
- determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
- planning (write measurable goals/outcomes and nursing interventions)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
a dear an contributor daytonite always had the best advice.......check out this link.