Help with careplan

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Hi, Everyone

Sorry I have not posted in a while, I have been in clinical and trying to study for tests. I have a Oncology and Musculoskeletal test tomorrow. I'm having a problem with my nursing dx on my careplan, my pt 86yr old F with r/o PE, v/s WINL, Crackle bilateral upper lobe on inspiration, edema lower extremities, c/o SOB, on 02 @ 2L, what else should I be looking for, what other nursing dx can I use beside Ineffective Air Clearance. Please help:o

Thanks

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Specializes in med/surg, telemetry, IV therapy, mgmt.

you need to go to a medical reference and look up the signs and symptoms of a pe, it's pathophysiology and check to see if your patient exhibited any of those symptoms and you just missed them. if you missed any, then you need to include them in your list of the patient's symptoms.

you can find internet information by searching some of these websites listed on this thread:

you can't make up nursing diagnoses for symptoms that the patient just doesn't have. did you assess their ability to perform adls? did you go through the patient's chart and copy down any abnormal lab values or symptoms in the doctor's h&p? do you have abgs?

sob is also a symptom of ineffective breathing pattern and impaired gas exchange. use a nursing diagnosis reference and see what other symptoms these two diagnoses have that you may have missed seeing in this patient.

the pathophysiology of a pe is such that a blood clot lodged in the lung deprives the lung of oxygen exchange to the area of the lung tissue that is cut off by the pe, subjects the patient to possible right heart ventricular failure and chest pain.

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Do you mean Pulmonary Edema or Pulmonary Emboli? Classic sign of Pulm Edema is Frothy Pink sputum. If you have Rales in Upper Lobes you have an emergency situation.

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Thanks for the infor on the careplan, but I took my 2nd test on musculoskeletal and Oncology today and got a 69, I failed it which means I'm out, there are 4 more tests and there's no way I can pull up may grade to pass because I failed the 1st to. The next test is HIV, Sexual transmitted Diseases and Breast Dysfunctions, which sounds easy but I need to drop now in order to return in the spring if I return. Thanks for all your help.:cry::cry:

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Sorry to hear that MP17

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