nurs. dx

aerorunner80, ADN, BSN, MSN, APRN · Feb 21, 2009

Is this a test question?

Daytonite, BSN, RN · Feb 22, 2009

i have an elderly client with medical dx of dehydration. in developing the nurs. dx. it is most important for me to:

establish nursing dx that are based on medical diagnosis.

focus on nursing diagnosis that affect fluid balance.

gather data to support actual nursing diagnosis

include actual and risk for diagnosis

there is very little correlation between a medical diagnosis and a nursing diagnosis. a nursing diagnosis is merely the identification of the nursing problem. all the stem of this question has told you is that a medical problem has been identified. in order to develop (identify) a nursing diagnosis (nursing problem) you need to go through the steps of problem determination. that means starting the nursing process. step #1: assessment. assessment is where you find abnormal data that will be the evidence that will support any actual nursing diagnosis (nursing problem) that exists.

let me give you an analogy. you take your car which is not running right to a mechanic. you tell the mechanic what you think is wrong with your car. do you think the mechanic diagnoses your car with the problem you just told to him? what does he do? if he is any kind of professional, he does an inspection (assessment) of your car before he does anything else. during that inspection he finds the things that are wrong about the workings of the car, reports to you what the problem with the car is (a diagnosis) and what it will take to fix it (a plan). that is the diagnosis and it was based upon an assessment.

as nurses, we do the same thing. a patient comes to us tagged with all kinds of medical diagnoses and conditions. we still assess them because our work is not the same as what the doctors do and requires additional information. that is why just knowing the medical diagnosis is not enough.

cindie mill · Feb 22, 2009

thank you so much Daytonite. Yes I am a Nursing Student and this is only a take home test. We were allowed help, work togehter, whatever we needed.

I also have another question. We have not done much work with NG tubes. I know what they are used for. The one in my question asks: if you are caring for a pt. with ng tube to continuous low suction.. client has vomited 100 ml of yellow-greenish fluid. most important for nurse to initially:

Okay, so are they referring to vomit in ng tube.... that is ok... then document... is it possible for the pt. to vomit around the ng tube... if so that is a problem... check placement....I hate how they word questions... I either read too much into them or not enough... There's no happy medium.... I'm really not stupid, just a wordy person. Appreciate any feedback

Daytonite, BSN, RN · Feb 22, 2009

the purpose of an n/g tube connected to continuous low suction is to keep the stomach decompressed and empty of secretions. if the patient has vomited 100 ml of yellow-greenish fluid it means that the n/g tube is not doing its job correctly/efficiently. you did not clearly state what the question was asking of you. i would check the patency of the n/g tube itself by irrigating it. check the placement of the tube and verify that it is positioned completely in the stomach. check to make sure the tube is connected to suction and that the suction is working. if the tube is patent and suction is working, reposition the patient by having them turn. sometimes repositioning the patient helps to facilitate movement of fluid in the stomach to where the tip of the tube is so it can be suctioned out.

cindie mill · Feb 22, 2009

See what I mean about reading too much into the questions. I knew you had to check the tube placement; but then I second-guessed myself. How good are u with chesttubes? I am pretty confident I have these ones mastered but if you don't mind....conferring can be a good thing. Thanks so much Cindie

cindie mill · Feb 22, 2009

I really don't think we have had much experience with ng tubes and therefore I find it really hard to come up with rationale for my decisions; and textbooks don't always cut it.

I know that checking tube placement is essential before admin. meds, etc...but then they throw another answer in, that sounds ok... like checking the residual, which will also show tube placement doesn't it? Anyway I am going with the gut feeling... crushing medication, dissolving with water and checking tube placement before administering...

cindie mill · Feb 25, 2009

can anyone help me..... if I have a closed-chest tube drainage system without suction, what as a nurse when I first hook it up would I expect to see.....

There is no suction, so is there still fluctuation (tidalling) with inspiration and expiration, even though there is no suction... I know you would expect to see some bubbles, representing the air leak.... but I'm not sure about the tidalling without wall suction... HELP!!

Daytonite, BSN, RN · Feb 26, 2009

can anyone help me..... if i have a closed-chest tube drainage system without suction, what as a nurse when i first hook it up would i expect to see.....
there is no suction, so is there still fluctuation (tidalling) with inspiration and expiration, even though there is no suction... i know you would expect to see some bubbles, representing the air leak.... but i'm not sure about the tidalling without wall suction... help!!

you should always see tidaling. this means that the chest tube system is still sealed and working. applying suction adds suction pressure to the system so drainage coming out of the wound can be pulled out faster.

seeing bubbles indicates that an air leak is still present in the lung and has not yet healed. the bubbles are air trapped in the pleural space that is now exiting to the atmosphere.

see http://www.icufaqs.org/chesttubes.doc