first med surg experience

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so my second day was good. i gave meds.my patient looked better from the first day.she was tolerating her pain even though she said it was a 5.she walked from her room to the end of the wall with assistance of course. i did my vitals assessment. i'm suppose to do a care plan but i dont know what to have for my diagnosis since she's not really complaining of pain. her only thing is that she wants to be able to walk on her own but i just try to encourage her and tell her that she's making progress and she needs to take it one day at a time because she could have it worst. i feel like i'm suppose to put things together from classwork and into the hospital but i dont find myself doing much to be "putting things together yet" my quest is when you guys do you assessment head to toe how do you go about it...do you ask all the subjective quests for each systems?and also when people have CABG why do they use the saphenous vein and what exactly do they do with it?

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Specializes in Maternal - Child Health.

If she's requiring medication for pain at 5 on a scale of 10, I do believe that pain is an appropriate nursing diagnosis.

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she was tolerating the pain at 5 on the second day.she only asked for it before she had dialysis.the whole day i was there she wasn't complaining of pain so i dont know

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look up what cabg means (the abbreviation stands for "coronary artery :redpinkhe bypass :redpinkhe graft" --spaces inserted on purpose.) then you can find out what the saphenous vein has to do with it all.

i strongly suggest that all students get a copy of the nanda 2009-2011 even if it's not assigned, and read through the tables of contents. you'll learn more there than you will in a half a semester of classes on nursing assessment and its relationship to what you're doing.

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Specializes in LDRP.

come up with diagnosis r/t the reason shes in the hospital. shes obviously not there to learn how to walk, so what is the most important thing.. she had a CABG im guessing? Think of possible risk for, or actual diagnoses that go along with someone whos had a CABG.

shes on dialysis? There are plenty of risk for and real diagnoses that go with that.. what are her electrolytes like? Why is she on dialysis?

and dont just wait for pt to complain of pain, because a lot of times they wont. they feel embarrassed like their pain isnt a priority and dont want to bother you.. you need to go in and assess pain accordingly using the pain scale as well as asking them where and the quality of the pain. Any pain above a 4 is not properly managed, and you should be intervening if possible, unless the patient denies meds.

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I had a CABG patient and also had difficulty in determining care plan info.

I had to remember that

A) the CABG is a procedure not a condition

B) all the symptoms that brought her for the procedure were no longer applicable AFTER the CABG.

C) It was all about the aftercare. Setting goals, patient education and keeping her compliant to her cardio care at home.

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