Quote from Jennifer_SN2013
I really want to be as smart as you someday lol! And this patient had no significant medical history. In the H&P, there was only what he presented with (dyspnea, c/o pain in throat, unable to eat solids). Nurses notes were the same, just re-establishing what the patient presented with. I was astonished at the lack of information, history and medical that I had to use for this paper. I am now going with Impaired Oral Mucous Membranes, Imbalanced Nutrition, Impaired Verbal Communication, and Knowledge Deficit regarding medication completion. We are only allowed to do four, however I am aware there are more that could be used. This has certainly been a challenge, and I have never struggled so much with a care plan....not even when I did my first one. I thank you for bringing to light the impaired gas exchange issue, i tried to fit the patient into the diagnosis because its what my instructor had said. I see now that my patient does not fit into that diagnosis and the ones I have decided to go with fit the patient, not the other way around!
If your instructor asks you about the impaired gas exchange be prepared to present you reasoning. That is another part of nursing....standing up for what you believe is right.
I see now that my patient does not fit into that diagnosis and the ones I have decided to go with fit the patient, not the other way around
This makes me feel good that you heard what I said and then followed through by trying to fit it yourself and after evaluation...you decided it didn't fit. You are now thinking like a nurse!
You should always use assess what your patient needs then decide what diagnosis fits.....not find a diagnosis and try to fit the patient into the diagnosis.
I might think about impaired swallowing for that can lead to dehydration and aspiration and after aspiration into the lung.....they can have impaired gas exchange.
Yeah....don't be astonished at the lack of information...with drive through admissions that are in and out in 24 to 36 hours most of the documentation is done post admission.
I've been a nurse a LONG time!!!!!!!!!!!!!!!!!!!! I didn't come by this over night. Yes we had to do care plans too....they use different terminology but the reasoning is the same. YOu are well on your way to being a good nurse by the reasoning you just used.