I had a earlier post I needed help, my patient assigned to me, admitted with ALOC, decreased speech and decreased interaction and a temp of 100.2
past hx cva -2002, seizure disorder, CAD HTN depression arthiritis, dementia, CABG, Afib for the last 2 years.
non ambulatory...left side paralysis
bp on admin 113/88 HR 83 Temp 100 o2 sat 97
when I had him for the day...his bp 113/81 HR78 temp 35.3 o2 sat 97
when speaking with him he does respond to you but it takes him a few minutes to formulate what he needs to say, with my short stay with him of a whole four hours he did intake water, the amount i do not know...he told me he was thirsty..most of the labs are good except for BUN 38 creatinie 1.24...
he is on oxygen at 2 litres per min
this is what i have so far and it could be completely incorrect
Ineffective tissue perfusion r/t decreased arterial blood flow (BECAUSE OF PAST STROKe) m/b altered level of consciouness.
Decreased cardic output r/t altered contractility (because he has Afib for past 2 yrs) m/b ???? how am I seeing it in him
Impaired physical mobility r/t muscular skeletal impairment m/b left side paralysis
am I on the right track and how do the tops ones look and I need 3 more and this is all the info i have
Specializes in med/surg, telemetry, IV therapy, mgmt.
another question i know there is a concern of his immobilty and dvt's does this need to be addressed?
after reading up on all his diseases and conditions and what you know after taking care of him, what do you think? a dvt is usually a problem when there is poor circulation in the lower extremities or a history of having had them before.
i have to use erickson's developmental stages..in one of my nursing diagnosis....age related....integrity vs despair,
. ego integrity is the ego's accumulated assurance of its capacity for order and meaning. despair is signified by a fear of one's own death, as well as the loss of self-sufficiency, and of loved partners and friends.
powerlessness r/t left side paralysis m/b patient's inability to perform adl's. is powerlessness suitable?
while this diagnostic statement works with someone who is depressed, it lacks depth.
powerlessness
is a psychosocial diagnosis. its definition is
perception that one's own action will not significantly affect an outcome; a perceived lack of control over a current situation or immediate happening
(page 190,
nanda international nursing diagnoses: definitions and classifications 2009-2011
). while a long term physical condition may be the cause of this, the
inability to perform adls
is not a specific descriptor of an outcome. i would describe the most important activities that have been lost. what about the patient's roles in life? his job? what about his control over decisions of his care? answers to this would reflect a more in depth conversation with the patient, his relatives or care givers who know him.
Between classes, clinical's and homework, there is very little time, the research that is required takes hour's, This RN program is only 2 yrs is this the average time in all college's? This my third quarter and I don't think I can go no stop like this for another year +.
All I can do is take one day at a time and see what happens!! Thanks for all your help, you really to explain, so it understood, you need to be a teacher!!!!
Specializes in med/surg, telemetry, IV therapy, mgmt.
i suspect that the reason everything is taking you so much time right now involves a learning curve. you seem eager to learn. once you start getting the gist of how to think these things through these assignments will move along faster. you are learning all kinds of new things. eventually you'll begin repeating them. it's like this care planning business. part of them is about following the nursing process. get the different steps of the nursing process clear in your mind and you'll be able to get the mechanics of doing a care plan a lot easier. it is a skill and you will get better with practice. i have the first 3 steps fairly well laid out. you can print it out and keep it to follow for reference when you are sitting down to do a care plan:
assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
a physical assessment of the patient
assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
[*]reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking
[*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
your instructors might have given it to you.
you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
[*]planning (write measurable goals/outcomes and nursing interventions)
goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
assess/monitor/evaluate/observe (to evaluate the patient's condition)
note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
care/perform/provide/assist (performing actual patient care)
teach/educate/instruct/supervise (educating patient or caregiver)
manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
[*]implementation (initiate the care plan)
[*]evaluation (determine if goals/outcomes have been met) - this is an assessment. you will specifically look for the defining characteristics that supported your nursing diagnoses to see if, or how, they have changed (improved, stabilized or gotten worse) as well as for the evidence of any new nursing problems.
You are the best, it is a learining process and I am taking baby steps towards the learning. I finally have my assessment down pat, I know it doesn't look like it from the last info I gave you, but there were other factors involved that day. I am hoping this week is going to be a better week!!!!!
I think BUN and creatinin levels along with immobility may call for Risk for impaired skin integrity related to impaired mobility secondary to left sided weakness? I think creatinine has something to due with skin and/or wound healing?
Risk for skin impairment due to poor circulation related to immobility secondary to left sided weakness. That I think is better than my previous one...
Yes, I did get it was evaluating the liver fuction, did you see my post on why they would of done a pt, ptt, inr on this pt, not on any blood thinners, and his pt is higher by about 10 secs?
Daytonite, BSN, RN
1 Article; 14,604 Posts
another question i know there is a concern of his immobilty and dvt's does this need to be addressed?
i have to use erickson's developmental stages..in one of my nursing diagnosis....age related....integrity vs despair,
powerlessness r/t left side paralysis m/b patient's inability to perform adl's. is powerlessness suitable?