Help with careplan...

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I have a patient that fell off of a roof and sustained a t3-t4 spinal fracture and multiple rib fractures as well as a hemo/pneumothorax. He has been sedated with ativan anf fentanyl since the accident. He had a thoracic spinal fusion since the accident. Upon assessment he opened his eyes to verbal stimulation. His pupils are equal, round and reactive to light. He has a normal heart rate and rhythm with capillary refill less than 3 seconds. His pulses are all all palpable (2+) and he has generalized edema 1+. He has scattered rhonci bilaterally and the left base is diminshed. He is on a vent with abnormal ABG's. Upon suctioning there is excessive bloody sputum. He has a productive cough and a chest tube draining a thick cherry color. He is NPO and has only has 12 hours of tube feed within the past 4 days. Prior to the thoracic fusion he was not moving or having sensation in his hands. Postoperatively he could not hold up just 2 fingers but he wiggle his fingers on both hands and had a strong grasp on one side and weak on the other. Lower extremities are fine. He has decreased rbc, hgb, hct, platelets, phosphate, and albumin. Increased AST. His fluid balance was +2577 for 24 hours. His meds include decadron (i do not know what this is for), nexium, acetaminophen, lidocaine, ativan\/fentanyl sedation drip. What do you think of these diagnoses.

1. Impaired gas exchange

2. Ineffective tissue perfusion (Cerebral) - my instructor told me to do this but i do not understand why and how or where to go with this.

3. Excess fluid volume

4. Risk for peripheral neuromuscular dysfunction

5. Moderate anxiety

Thanks for any help...

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

the last time you asked for help with a care plan i gave you the same advice i am going to give you now. . .follow the steps of the nursing process to help you organize this care plan. everything is dependent on your initial assessment of the patient.

step #1 - assessment. assessment consists of:

  • a health history (review of systems) - patient fell off of a roof and sustained a t3-t4 spinal fracture and multiple rib fractures as well as a hemo/pneumothorax. he has been sedated with ativan and fentanyl since the accident and had no movement or sensation in his hands prior to surgery. he has had a thoracic spinal fusion.
  • performing a physical exam - opens eyes to verbal stimulation, pupils are equal, round and reactive to light, has generalized edema 1+, has scattered rhonchi bilaterally and the left base is diminished, has a productive cough, excessive bloody sputum with suctioning, a chest tube draining a thick cherry color, on a vent with abnormal abg's, postoperatively he could not hold up just 2 fingers but he wiggle his fingers on both hands and had a strong grasp on one side and weak on the other, fluid balance was +2577 for 24 hours.
  • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - no assessment of the patient's adls has been provided
  • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - you need to look up the pathophysiology of a t3-t4 fracture and injury to the spinal cord and complications the patient can have with this kind of injury
  • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - on decadron, nexium, acetaminophen, lidocaine, ativan and fentanyl - it is not good enough for you to say "i do not know what this is for". then, you need to look the drug up and find out why it has been ordered and why he is getting it. you can find each of these drugs on drugs.com http://www.drugs.com/. decreased rbc, hgb, hct, platelets, phosphate, and albumin.

step #2 - determination of the nursing problems (nursing diagnoses). this is based on the abnormal data that is found during the assessment in step #1. every nursing problem has a set of signs and symptoms that must be present for the problem to exist.

  • what are you doing about this productive cough, rhonchi and bloody sputum the patient is having. that's not impaired gas exchange. it's a different nursing diagnosis.
  • what about his ability to only wiggle 2 fingers on both hands and had a strong grasp on one side and weak on the other? can he walk? move his legs? this has to do with mobility. there is a diagnosis for this that has been completely ignored.
  • how does he pee and poop? does he do it by himself or does he need help?
  • is he in any kind of pain?

- - - - - - - - - - - - - - -

impaired gas exchange

where is your evidence to support the use of this diagnosis? i don't see it. abnormal abgs isn't enough evidence.

ineffective tissue perfusion (cerebral) - my instructor told me to do this but i do not understand why and how or where to go with this.

this is why you need to examine the pathophysiology of the patient's injury. was there a head injury?

excess fluid volume

what is your evidence?

risk for peripheral neuromuscular dysfunction

this is based on what?

moderate anxiety

there is no nursing diagnosis titled
moderate anxiety
.

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Impaired gas exchange - He is on a vent, hemo/pneumothorax, abnormal abg's, smoker, scattered rhonci, decreased left lung base, rib fracture, and t3-t4 effects intercostal muscles.

Ineffective airway clearance is likely the one you wanted me to use...

Ineffective tissue perfusion - No, surprisingly the patient did not have any head injury which is why I am confused.

Excess fluid volume - +2577, primary drip decreased from 150 to 50 mL/hr, decreased urinary output, 1+ edema, decreased hgb, hct, rbc

Risk for peripheral neuromuscualr dysfunction - he was not able to move his hands prior to surgery, postoperatively he was able to and had sensation, more so on one side than the other.

Impaired mobility - As far as mobility he is sedated and intubated. He has a lot of random movement in the legs and follows verbal command when asked to wiggle toes, push against hands, etc. He is currently dependent for all ADL's.

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

scattered rhonchi, decreased left lung base, the productive coughing are not symptoms of impaired gas exchange. they belong to ineffective airway clearance.

ineffective tissue perfusion, cerebral - look at the effects of the medications that are being used to sedate him.

risk for peripheral neuromuscular dysfunction - is because of his primary injury. read about the pathophysiology and complications of t3-t4 injuries.

impaired mobility - as far as mobility he is sedated and intubated. it is restricting his movement and is therefore creating a problem. mobility is a primary need of all humans. without full mobility he will develop serious deficits in his ability to move over time so that when the sedation is finally withdrawn what kind of physical functioning is he going to have? part of our job is to preserve and maintain whatever ability he has to move.

he is currently dependent for all adl's - there are nursing diagnoses for these. helping patients achieve their adls is a primary job of what we nurses do. you can't just ignore these on a care plan.

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