I have been somehow ... completing care plans w/o a med surg book! I just have NOT had the money, and I think I am finally going to be able to get it this weekend. I am so very excited. Although somehow, I have managed to pull off High B's to High A's on all my care plans, this will make the grand difference. I am going to go in and get it tomorrow... hopefully, for now I'm trying to complete a care plan from todays clinical (today was an odd day ... she had us pick the pt today and turn the cp in tomorrow)
My pt is in her late 80s. She is a diabetic and anemic.
Chief complaint: Fever.
Medical Diagnoses: Pneumonia. ARF secondary to dehydration.
+ = high - = low
K +
Cl +
CO2 -
Gluc +
BUN +
Creatine +
Low Hct + Hbg
CXR lead physician to diagnose pneumonia, due to infiltrates.
I feel the K could be high due to a) unmanaged diabetes. b) The ARF
Cl because of ARF
CO2, I'm sure that the current ARF is causing a pH imbalance.
BUN/Creatine due to the ARF.
I hope I can refine and make more sense tomorrow.
As of right now I believe the following are problems. (these are the issues, not the Nursing diagnoses)
The...
-I believe that due to the respiratory discomfort, she quit drinking fluids causing dehydration, leading to the ARF
-unmanaged diabetes
-Her Electrolytes are completely abnormal
-she's bed bound... this could affect her skin
side note* here's the weird part ... I did not even get to meet the pt. Why? b/c my prof had me follow another health care worker, then come down to the med surg floor and pick this pt to do careplan over*
I guess the purpose of this post is to see if I'm going in the correct direction. The comments always help and I appreciate them. May I have feedback on what I think are issues?
I believe the dehydration is the primary issue... we need to choose One Nursing Intervention and One Collaborative.
Just off the bat ... Nursing interventions I would assume are assessing skin turgor, assessing the input/out put.
the collaborative would be administering fluids as ordered.
Oh I reallyyyyy can't wait for my med surg book. I'm sorta of envious of the others with their book... it looks so nice and informative... and I've been having to somehow do with what I have ... but hey... it's worked (=
When you take NCLEX, never never never choose the distractor that says something like, "Refer to dietary," "Call social worker," "Notify chaplain," etc. The NCLEX wants to know what you the nurse does, not to see you the nurse turf it off to another discipline. There will always be a nursing intervention they want to see that you know. This may be (and often is) "obtain more information" in some way, either by asking the patient or family member something like "Tell me more about that" or "What did you do about that?" for example.
Sometimes notifying the physician is on the list; if it's part of the list, fine. But it's rarely the only thing you do. Even in an emergency situation, you don't just go to the phone. There's something else you should be doing-- raising (or lowering) the head of the bed, compressing a bleed, bagging, unblocking the Foley, taking VS and giving prns, something that requires nursing knowledge and judgment. NCLEX is to see if you have those qualities enough to be an RN, so that's why they ask.
"Continue to monitor" or "CTM" is a phrase seen often in charts of facilities who get sued for deficient custodial care. I personally loathe the phrase.
tinks599
35 Posts
"Continue to monitor" or "CTM" is a phrase seen often in charts of facilities who get sued for deficient custodial care. I personally loathe the phrase.