cminmd

Tomorrow I have a patient who is on telemetry. This will be my first patient on a cardiac monitor and I was wondering what I need to know. They use a 5 lead system and I think I will have to replace the leads after AM care. Also, what do I need to look for? I am confident I will notice Afib, Vfib, Vtach and G*d forbid- asystole, but what else should I know to look for. Is there something about a u wave indicating a prior heart attach? How do I document telemetry? Do I just include it in my new patient assessment then just document problems? Any advice you could give would be great!!! Thanks!!!:heartbeat

That's it! Thanks so much and that is a terrific website!!!!!

I think it was something like mosselles? She said it was used to stop the bleeding- does Mercurochrome or benzoin do that? I thought they were just to kill bacteria? It definitely had a strong chemical smell and had an iodine metallic sheen to the golden brown.

I was at an OB clinical rotation watching colposcopy procedures. What is the name of the thick golden brown liquid (begins with M) that the physician put on the biopsy site with a cotton swab to stop bleeding? I wrote it down on my clipboard, but it got wet and now I can't read it. Help!

No worries, Mate! I have Lewis as well, but maybe they consider that information more "diagnosis" and out of our sphere of practice, but it seems like that is the type of questions patients would ask a nurse "in the room". The only ones I have seen that are to be reattached later are the double ostomy cases, but I have only seen one and that was for a gun shot victim, not due to a disease process. That is why the lewis comments seemed very atypical to me. I was wondering if in the real world- disease is full removal, but trauma is reversible? I don't know.

Not to be judgemental, but if you can build a pouch for urine that doesn't leak, why can't you build a pouch for feces that doesn't leak? Just by the viscosity of the two samples you would think that it would be harder to keep a liquid from seeping than a runny or semi-formed solid. And no, my text book does not cover it that is why I asked. The text book makes it sound like the majority of patients would not have ostomies. It implies the only patient who would get an ostomy is someone who had rectal cancer or diseased rectal tissue, but I have seen so far that many patients without cancer, or highly placed UC or Crohns still get ostomies. The book says ""Patients with UC may also need to have a total proctocolectomy. In both situations the surgeon will form an ileal pouch anal anastomosis. If the anal sphincters are not diseased they can be left intact, if not the person will need to have a permanent ileostomy." I was just wondering why the book (which I know is highly theoretical) is so different from what I see in practice. I was wondering if EBP showed that leaving any portion of the intestine makes relapes more likely? pointed to the n is that the disease will spread anyway so might as well remove it all? Thanks for you help, you make me feel so welcome.

We are just starting our section on ostomies, but I have seen several in clinical settings. I have so many questions. First- why does a urinary diversion not drain out continually, but a fecal ostomy does? I think patients would much rather have to go to the bathroom every hour than have to strap on a bag of poo all day. I had a 22 year old guy with ulcerative colitis who refused the ostomy despite all the drs pushing for that option. I didn't say anything, but I can't say I didn't agree with him. I know I could not deal. Also, why is their so much variations between ostomies. Some are huge and protude, others are much smaller and only slightly humped. Is that surgical skill or what accounts for the difference? Also placement. I know that placement depends on which area of the intestine is damaged, but does placement site make some ostomies better or easier for patients? Thanks for any help!

This is what makes me nervous. At our school we are taught that you 1. Must always use Y tubing with normal saline. 2. You have 30 minutes to start a transfusion (not 15) 3. that the blood should transfuse slowly 3-4 hours. 4. use at least an 18 gauge needle to avoid RBC trauma 5. if you have any type of reaction to stop the transfusion and send the tubing and blood back to blood back and start a new bag of saline to dilute irritant. We also have a different schedule of vitals- before you get the blood, before you start transfusion, +15, +30, + 1 hour, +2 hour, +3 hour and after transfusion finishes. I am worried when we take the NCLEX that someone is going to get something wrong because we are all taught something slightly different!

Can "dying" be an abnormal "assessment? I am really confused because when he reviewed my concept map he made it sound like comfort care/ hospice was an actual ND. So I went home with my NANDA and nothing. My patient is mentally altered by the HEncephalopathy so I don't think I can put Grieving, Impaired spirtuality, of Ineffective coping. I was thinking "Disabled family coping" but I have pretty thin evidence to support it. All I have as a D-i-L coming by to say that her husband was really sensitive and she wanted to come by to see how her F-i-L looked before she would bring the older grandchild to see him. I asked her if she wanted to speak with a physician or a minister (at an Adventist hospital) and she declined both, but I don't know if that relates to any spirituality issues or she just was in a hurry with a toddler in tow. Any suggestions?

I have a pt with end stage liver and kidney failure. During the week they changed his treatment plan to that of comfort measures only. They pulled the NG Tube, stopped all meds other than for pain and stopped all blood tests. I have to do my concept map- what types of ND's would show that change?

I don't get how you go to nursing school online? If you just get your prereqs then have to transfer you might as well go to your closest cheapest community college. How do you take clinicals? This is a hands on profession. I worry you would spend all that money and not be able to get a job because hospitals wont want to train you.

The patient is in end stage liver disease, renal failure, hepatic encephalopathy, anemia, jaundice, hepatic portal hypertension causing E + G Varices all due to cirrhosis/ Chronic Hep C. He has SO many problems, but only a few that we are still treating so that limits what I can do for NDs because I have to have outcomes and interventions. For example, they are giving him lactulose to cause diarrhea to help waste base and get him closer to balance. Can I use diarrhea as a ND if it is something his treatment plan is actually trying to cause? This stuff is so confusing!!

As a newbie I appreciate the color system. I always feel like a perv trying to read nametags! I don't see the point of only nurses wearing a color. The only hospital I have clinic-ed at had everyone in uniforms- DRs were green scrubs (only if they were operating that day) or long white lab coats over street clothes. Nurses were in navy blue, Resp in red, radiology in black, speech and psych wore short white lab coats over street clothes. Physical therapy in "salmon" (totally pink!!) and I cant remember seeing anyone from OT. The only people I felt really bad for were the PCTs that had to wear these G-d awful smocks over navy blue pants. Yikes. But they were free, so that was good with what they get paid. We would always tell the patients- Remember we're all Navy Nurses! Except us student nurses that were dressed in so much white you could make a patient snow blind!

Can I put risk of aspiration? The patient was given an NG Tube for feeding because he was at risk for aspiration. Can I put that he is at risk for aspiration due to mechanical irritation of Esophageal Varices?

Does Maslow have sub-levels? In our school they teach us the Hierarchy of Needs, but it seems very general. Physiological, Safety, love Self esteem, self actualization- we never went into what goes on within a level. So I know you don't talk about relationship issues with a patient who is in physical pain, but how do you prioritize between needs in the same category?

wow!! You should be a professor! Or a tutor!! Since I can't send you real brownies, I will just say THANK YOU!!!!:bowingpur:monkeydance:

Hi Super Nurses, My fellow students and I try to help each other with evaluating our ND's and patho each week, but we miss a lot because...well, because none of us know what we are REALLY doing! How does this sound? Nsg Dx # 1 Deficient fluid volume related to blood loss and third spacing loss as evidenced by ascites, edema and impaired GI absorption as evidenced by bloody stool, 20 inch protuberant abdomen with fluid wave, +1 edema in hands and feet and less than 600 mL input/day. Nsg Dx #2 Altered Tissue Perfusion: renal related to impaired organ function as evidenced by low blood pressure, hematuria, decreased and concentrated urine output Nsg Dx #3 Imbalanced nutrition less than body requires related to impaired GI absorption as evidenced by height of 5'11, 145 lbs and BMI of 20.2, loss of 15 lbs in 3 weeks, signs of muscle atrophy in neck and arms and NG tube return of feeding 60 mL at rate of 15 mL/ hour. Presentation- Syncope and partial LOC related to GI bleeding due to rupture of gastric and esophageal varices. Pathophysiology- Gastric and esophageal varices are small collateral veins that dilate fully due to blood diverted from the liver as the body tries to compensate for hepatic portal hypertension. The continual high-pressure environment makes the vessels enlarged and prone to rupture at the sight of comminuting or easily ruptured by gastric acid, rough food and increased pressure from vomiting, sneezing or coughing. The increase in liver vessel pressure is a result of Cirrhosis. Cirrhosis refers to the replacement of normal hepatocytes with fibrous scar tissue. The combination of fewer liver cells and scar tissue blocking the normal flow pattern causes blood to back up increasing the hepatic pressure as more blood volume processes in a smaller area by fewer cells. Inflammation of hepatocytes from cirrhosis is due (In Mr. TE"s case) to the Hepatitis C virus. Hep C is an RNA virus in the Flaviviridae family, genus Hepacivirus. It is a small double enveloped single-strand RNA virus. HCV replicates in the liver and is present in the serum during acute and chronic infections. More than 60% of HCV patients will progress to chronic status with approximately 20% leading to cirrhosis. Serum ATA levels best reflect hepatocellular injury and may fluctuate with the viral load. Do you think the 3 nd's are in the right order?

How do I teach a comatose patient? This is a care plan for an assignment, not something I will actually do with a patient. In "the real world" I would not have the artificial requirement of one teaching, one risk, 6 actual- I would just make the nd's base on the patients true needs. It is hard to know the difference between medical diagnosis and symptoms. His official medical diagnosis is hepatic hypertension, hepatic encephalopathy, cirrhosis and Hepatitis C. So things I observe- jaundice, ascites, edema are also his medical diagnosis?

I have a patient that has hepatic hypertension causing E/G varices, hepatic encephalopathy, protuberant ascites with fluid wave and + 1 edema in his hands and feet. What can I do for a pt teaching nursing diagnosis? His family has not been available except by phone. Would you pretend to teach the family? Also, many of the things I would normally do, they are not doing because his liver failure is so advanced. For example, he has significant fluid deficit with concentrated yellow urine, dry mucus membranes and slack tugor, BUT they are restricting his fluids to 50 ml in his IV PGBK, the fluid you need for NG tube medication and oral care on a stick sponge. I am doing stuff like comfort measures with lotion and oil, monitoring IO, daily weight ect, but can't directly fix the problem. What do you suggest? Also, does Jaundice have a ND?

Hi! I am a fellow nursing student - so take my advice with a grain of salt!!! I also have a patient with GI Bleeding, but his is due to e/g varices. I am doing my nursing diagnosis on the symptoms like fluid volume deficiency due to blood loss and diarrhea.

Thank you so much!! You are right. I need to drop down anxiety because physical needs come first!

acute pain related to surgical incision, drains and prolific abdominal infection with multiple abscesses as evidenced by patient's report of pain as 6/10, clenched teeth upon movement, grimacing and guarding. risk of falls related to lower extremity weakness, orthostatic hypotension and patient walking bent over due to abdominal pain resulting in limited field of view. anxiety related to traumatic medical diagnosis, financial stress and marital discord as evidenced by patient crying, snapping at family members, working while hospitalized and reporting fear over losing insurance coverage. impaired tissue integrity related to surgical incision and invasive lines as evidenced by 6 inch midline incision, well approximated, with two bilateral drains held with sutures. risk for infection related to large abdominal wound and drains. nausea related to post surgical anesthesia and surgical manipulation of the intestinal organs as evidenced by patient reports of nausea after fluid intake and upon moving, anti-emetic medication and post operative abdominal agitation. fluid volume excess related to electrolyte imbalance and impaired renal function as evidenced by edema in lower extremities and decreased and concentrated urine output. constipation related to surgical trauma and opioid medication regimen as evidenced by decreased bowel sounds, clear liquid diet and no bm since surgery. hi everyone, i am finally finished lurking and want to join in on the great resource that is all of you!! my patient is a 54 yo cau, female; 3 and 4 days post op from an emergency perforated appendix. surgical report drained over 1 l of purulent fluid from many abscess thoughout peritoneal cavity. surgeon also indicated multiple growths orginating from large turmor on left kidney. referred to oncology for followup when appendix crisis has passed. additionally, the patient is going through a divorce that will be finalized within the next month or so. despite all her physical issues she is filled with anxiety over health insurance as she is leaving her husbands plan upon disolution of the marriage- and now she has a significant pre-existing condition. how do i prioritize my list of diagnosis? what part should anxiety play and what interventions can nurses do to help? it might be easier to skip the "psych" stuff and stick to physical issues, but it really seemed like i would be ignoring her biggest issue. she was working the phones, would break into tears, would snap at family and push herself because she felt she needed to get better right away to get as much done on the cancer before the clock ran out. any suggestions?