I'm really at a loss here, any help is appreciated. My patient is a 57-year-old female with a history of diabetes, partial hysterectomy, hypertension, and hyperlipidemia. She was admitted 16 days ago with right-sided stroke and she now has a flaccid left side. She is a medium fall risk vital signs of been stable, has no known drug allergies, hearing is intact, but attends occupational therapy for one and a half hours a day for auditory speech and balance. Attends physical therapy from more than 35 minutes per day.
Labs:
Troponin-
Na-137 mEq/L
K-3.4 mEq/L
Chloride-100 mEq/L
HCO3-27 mEq/L
BUN-8 mg/dL
Creatinine-0.7 mg/dL
Glucose-87 mg/dL
Liver Function-Normal
AST-15 U/L
ALT-20 U/L
WBC-11.7 x 10^3µ/L
Hgb12.6 g/dL
Hct-36.5%
Platelets-338 x 10^3µL
My problem here in my opinion, is a lot of her diagnoses are risk for diagnoses. However my instructor does not want us to do at risk for in our care plans, she wants us to do our care plan on actual problems. While taking care of this woman the only thing I noticed was her left-sided weakness, her memory and speech seemed completely intact to me, she seemed to have very little complications r/t the stroke, she was sharp as a tack. I have to list all of the diagnoses that apply but i'm only doing a care plan on 2 of them and it has to be the TOP 2, i have impaired physical mobility, but thats all i have, she doesn't even want us doing anything like Bathing self care deficit (anything to do with ADLS), so i guess basically she wants us to make it up. If i'm leaving anything out let me know and i'll give you the information.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
She is still a bed side nurse. I guess what she's trying to accomplish by keep us away from risk for diagnoses is to keep is from taking the "easy" way out of a care plan, she wants to see that we can come up with a.e.b and such is my best guess. I honestly have no clue, like I said we aren't actually carrying these out but when your patient seems otherwise intact it's harder to not do what fits.
Also now I'm doing my postpartum care plan on a c section mom...what would the better Dx; impaired physical mobility or activity intolerance? She says that it hurts to walk too much, changing positions frequently hurts as well.
Again...you have told me what she medically wrong. What does your assessment reveal to you?
Pain...that is a good one. If you have ever given birth pain is pretty up on the top of the list. even a section Mom is she labored at all can still have pain in the perineum as well as surgical pain.
But what else?
Is this her first baby?
Is she breast feeding?
Is this her first pregnancy?
How many days post op?
Was this after prolonged labor?
What was the EBL?
Any surgical patient that isn't moving post op is in danger of ______
Abdominal surgery is a risk for ineffective breathing pattern as is opiate use (especially if spinal/epidural morphine was used). Since pregnancy causes blood to clot more easily, and a post op patient doesn't move as much, risk of PE is increased.
Use of epidural/spinal narcotics also can cause problems with voiding as does having a foley cath.
If your patient is breast feeding, there's another one for you as pain can cause more difficulty in handling the infant, finding a comfortable position, and even let down.
If she had a prolonged labor before the C/S, she is at increased risk for PPH (especially if she had prolonged rupture of membranes and was possibly starting to get an infection), other reasons she is at risk for increased blood loss, other than just post op
I've got the majority of my care plan finished I just wanted to know which would be most appropriate I guess. Do you think pain would be more appropriate than either of the other 2?
3rd baby, second c-section (planned), 2 days post op, pph the night before I provided care. She was refusing all pain medications, she said she was only in pain while moving around too much, some walking (like to the bathroom and back and just general ambulation in her room) but walking in the halls was too much. She's both bottle and breast but I also used ineffective breast feeding bc she was bottle more than breast bc she was worried the baby wasn't getting enough at the breast. Small amount of lochia, fundus firm midline @U-1 voided q2-3h during shift
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I've got the majority of my care plan finished I just wanted to know which would be most appropriate I guess. Do you think pain would be more appropriate than either of the other 2?
3rd baby, second c-section (planned), 2 days post op, pph the night before I provided care. She was refusing all pain medications, she said she was only in pain while moving around too much, some walking (like to the bathroom and back and just general ambulation in her room) but walking in the halls was too much. She's both bottle and breast but I also used ineffective breast feeding bc she was bottle more than breast bc she was worried the baby wasn't getting enough at the breast. Small amount of lochia, fundus firm midline @U-1 voided q2-3h during shift
Wow....HgB 7.2...I would think about deficient volume with the PPH. Her B/P is a little low and diastolic a little high indicating her heart is straining to compensate. I would say pain is important and deficient knowledge as she needs to be educated about taking pain meds to facilitate ambulation to prevent complications. I would think more activity intolerance due to pain
Wow....HgB 7.2...I would think about deficient volume with the PPH. Her B/P is a little low and diastolic a little high indicating her heart is straining to compensate. I would say pain is important and deficient knowledge as she needs to be educated about taking pain meds to facilitate ambulation to prevent complications. I would think more activity intolerance due to pain
Thanks! I did do deficit volume but we have to have at the very least 6 Dx and we only have to do the care plan on the 2 priority Dx.
Esme12, ASN, BSN, RN
20,908 Posts
Again...you have told me what she medically wrong. What does your assessment reveal to you?
Pain...that is a good one. If you have ever given birth pain is pretty up on the top of the list. even a section Mom is she labored at all can still have pain in the perineum as well as surgical pain.
But what else?
Is this her first baby?
Is she breast feeding?
Is this her first pregnancy?
How many days post op?
Was this after prolonged labor?
What was the EBL?
Any surgical patient that isn't moving post op is in danger of ______
Abdominal surgery is a risk for ineffective breathing pattern as is opiate use (especially if spinal/epidural morphine was used). Since pregnancy causes blood to clot more easily, and a post op patient doesn't move as much, risk of PE is increased.
Use of epidural/spinal narcotics also can cause problems with voiding as does having a foley cath.
If your patient is breast feeding, there's another one for you as pain can cause more difficulty in handling the infant, finding a comfortable position, and even let down.
If she had a prolonged labor before the C/S, she is at increased risk for PPH (especially if she had prolonged rupture of membranes and was possibly starting to get an infection), other reasons she is at risk for increased blood loss, other than just post op
Tell me abut this patient!