nurs. dx

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

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.

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.

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