care plan help ... naturally.

[katiebry1031]

i just need a little bit of guidance. i need to write a 3 part nursing dx from our clinical this week. this pt was admitted to the facility for s/p fall but her actual diagnosis upon admission was acute metabolic encephalopathy, anemia, and htn. she is mildly confused but alert and oriented x3 but just has to think about the answer for a minute. pt does have ecchymosis on her upper extremities related to anemia. she has also decreased ROM in her RUE due to osteoarthritis and rotator cuff. she has B/L hand osteoarthritis. she is a very pleasant female. she also has urinary incontinence but its more nocturia. does wear briefs, but didnt have incontinence while i was present. I was thinking of writing mild confusion r/t chronic illness as evidenced by ... and then i got stuck. I need some help or some guidance would be nice. thanks. we only had a half day of clinical so its hard for me to gather that information.

[nurseprnRN, BSN, RN]

"what if you have a pt upon assessment has no abn or issues with a system, what do yu do then?"

that person is probably not in a position to receive nursing care.

if the person is in a position to receive nursing care, you need to know why, and then need to figure out what problems they could have, how to do a nursing assessment for those problems, decide whether they exist or not (or are possible/potential), and then prescribe what nursing will do about it.

look a little harder. don't expect to rely solely on your impressions and judgment, because by definition, yours are a little, um, unformed right now. that's why you are in school, to learn more.

[xtxrn, ASN, RN]

What if you have a pt upon assessment has no abn or issues with a system, what do yu do then?

Hope they get sent home, before they get sick in the hospital??? :)