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using the nursing process. . .
step 1 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
step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of all the abnormal assessment data
step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use
risk for impaired skin integrity r/t obesity.
impaired gas exchange r/t alveolar-capillary membrane changes aeb sob, dizziness while standing/walking, o2 sat 92-94%, increased respirations, and skin pallor.
activity intolerance r/t insufficient oxygenation aeb dizziness while walking, and sob.
I should have given you more of the information that I had. When I was thinking of the activity intolerance, when he removed his NC, and was on RA, his sats dropped to 87% or so. He would remove it to walk to the bathroom,etc. As soon as he would get to the br, he would have to rest before taking more action. Then, he would go back to the bed, and have to rest before lifting his feet onto the bed. This fatigue was accompanied with very labored breaths. I did do his vitals before going to the br, and his bp went from 98/64 to 102/68, and respirations went from 22 bpm to 26 bpm O2 dropped from 94 to 87 this particular time. After getting him back in bed and situated and he took the time he needed to calm down, (15-20 mins), bp-R-O2 returned to "his" normal.
As for the Risk for impaired skin integrity r/t obesity....I was in the mind frame that he was pretty much bed bound, he was too large to change positions as he should have, and I was thinking of the stress on the pressure points along with the continually dampened sheets (from some mild sweating). This information I left out as well.
With the Impaired gas exchange, I understand your comments, and now realize I was off on this one completely!! I am struggling so much with these careplans....this pt had so much I could have chosen from, and I drew a blank on all of my options.....thank you so much for your replies. Talking it out helps more than you can imagine!!! I ended up going over these with my instructor this morning, and she helped me out, but I felt very unprepared for clinical, and I don't like not being prepared. I am sure this rookie will get the hang of this in time.....thanks again!!
Talking it out helps more than you can imagine!!! I ended up going over these with my instructor this morning and she helped me out, but I felt very unprepared for clinical, and I don't like not being prepared. I am sure this rookie will get the hang of this in time.....thanks again!![/quote']Yes, it comes with time and experience. Seeing what patients experience also helps. Putting what you see together with what you learn from textbooks also helps. Good luck!
RNnTrainin'
93 Posts
71 yr old w m 326.5 lbs admitted for bronchopneumonia, COPD exacerbation.
For some reason I am having trouble. I love doing care plans, but I don't know if all of the exams and tests are stressing me out or what, but I cannot think clearly. Pt has sleep apnea, emphysema, abnormal cholesterol, chronic insomnia, benign prostatic hypertrophy, and neuropathy. He is a non smoker. resp are 22-24 deminished & wheezing, bp is fine, pain rated at 1/10, oxygen is 92-94 w/2L/min via NC. sputum is thick, greenish-white in color,+1 edema in ankles & feet bilateral p cyanosis. Turgur 3+, exhibits pallor, P is in normal range, however weak, but even. abdomen is distended w/tenderness upon palpation.
Like I said, I know these nursing dx could be better, but I am having a brain block!!!
1. Impaired gas exchange r/t alveolar-capillary membrane changes aeb SOB, dizziness while standing/walking, O2 sat 92-94%, increased respirations, and skin pallor.
2. Activity intolerance r/t insufficient oxygenation aeb dizziness while walking, and SOB.
3. Risk for impaired skin intergrity r/t obesity.
Any suggestions for me? Thanks in advance........