care plan help!

Nursing Students General Students


okay so i have a few questions....first of all, for my medsurg clinicals we were required to do a 17 page health hx on 2 patients throughout the first 5 weeks and then do a SOAP note for the rest of our patients, with the exception of a day we observed a surgery. my first patient i decided to do a SOAP note on, the second day i observed the surgery, i had 1 patient last week, we didn't have clinicals at all this week, and then next week we have 1 clinical in which i plan to do my 2nd health hx and then we are done. so my health hx packets are due next wednesday during our evaluations. ANYWAY, the patient i had last week did not agree to answer any of my questions (she answered 2 out of the whole 17 page packet)...some of the questions in my health hx are from my point of view (specific labs, info about meds, NANDA labels, etc) others were questions i was supposed to ask her. i tried talking to her then she told me not to ask her anymore questions, so i didn't. so my question is...i HAVE to turn this health hx in next week, should i just put N/A on everything I don't have? i don't want to make up answers but i feel like I didn't do what was asked of me as a student. i tried to talk to her, i can't make her talk back. i just don't want points deducted :(

anyway, so of my patients health history i received i am trying to come up with 3 priority NANDA labels...we are on a CCH unit at the hospital, she was admitted to a different hospital on 7/15 for a R pleural effusion and pericardial effusion. she had a pericardial window with CT to right side (per the patient's chart) on 7/17 as well. she was then moved to this floor on 8/2...i took care of her on 9/ what exactly would her diagnosis be? she has been in the hospital over a month...would it be the R pleural effusion and pericardial effusion even though that was from being admitted to a different hospital. on her chart she doesn't have an Adm Dx for this facility but has her health history and procedure list. i'm so confused :( also...i need help picking the 3 priority NANDA labels...i was thinking Impaired Gas Exchange, Ineffective Breathing Pattern, and then Impaired Skin Integrity (she also has a healing Stage II Pressure ulcer on coccyx)....would those be priority??? i feel like i should have something for the Pericardial effusion as well... Sorry for so much rambling...I am still new to care plans and everything. Thanks for your help!

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