RNstudentc/o2010

Hi, I just have a simple question: If I were to write the pt's subjective data in "" marks, but I paraphrased and it was obvious that I paraphrased, would that be wrong? Ex: The pt is afraid of the dark and must have a light on at all times. Subjective documentation: a.) Pt AAO X 4, sitting with erect posture. "he is scared of the dark and says that he needs a night light." Reassurance given. Small light obtained from management, and after given to the pt, anxiety subsided. b.) Pt AAO X 4, sitting with erect posture. "I need a night light. I am scared of the dark." Reassurance given. Small light obtained from management, and after given to the pt, anxiety subsided. In example "a," I paraphrased. Is this wrong? Thanks!

Well, thank you. That clarifies a lot. I was leaning towards that concept, but I was not sure. When one side fails, the blood has to go somewhere, right?

thank you for your help. i do that a lot, i really need to break myself of trying to figure out the medical dx. i'll probably stop doing that when i get used to the nursing process. i think that several factors are at play with his dehydration. i think that he is probably dehydrated because of excess diuretic use (can i say this?) prescribed to treat his htn. i just find it odd that he is still taking a diuretic when his admitting dx is dehydration. i know that circulation comes before fluid status, but it just seems like they would consider prescribing something else. perhaps his heart is easily overloaded because of its poor condition created from poor htn management. he is also malnourished, so maybe these two go together. i know that he lives by himself and that a hospitalist comes by to help him with his adl's and home care, but other than that i don't think that he has anyone really checking on him that often. he cannot walk, so i am thinking that a lot of this malnutrition and dehydration is attributed to the fact that he cannot just get up and walk to the refrigerator to get something to drink or something to eat. he is forced to rely on others because of his medical condition. dehydration/malnutrition are risks of several of the meds that he is on as well (protonix, lasix, coreg, atrovent, and prednisone). his 24h i&o was really imbalanced: 750 cc i to 4400 cc o, and all that he ate was his breakfast. he told me that he did not like the food at the hospital, and he could not tell me his favorite foods that he usually eats at home. so, he probably disagrees with his dietary restrictions (cardiac diet). i don't think that he eats every day, really. he told me that he only has 1 bm a week, and he says that they are normal. also, i think he has a knowledge deficit because when i asked him why he thinks that he only has 1 bm/wk, he said that he did not eat that much. these last two visits to the h have been a result of the hospitalist referral, never family referral. when i explained to him why he needed to drink more fluids to motivate him to drink more (because he is in the hospital for not having enough fluids in his body), he appeared confused and did not say anything. so, maybe the dehydration is r/t limited mobility, diuretic use, overall decreased intake, knowledge deficit, and elevated rr. maybe the malnutrition is r/t overall decreased intake, food preference, dietary restriction, decreased mobility, lack of appetite (common in old age). am i missing something here? his admitting dx is dehydration and they later confirmed chronic renal failure. the past few times that he was admitted to the h was for either dehydration or low bp. here are the ndx's that i have created. do you think that i have made any errors? 1.impaired gas exchange r/t chronic respiratory process, alveolar-capillary membrane changes, ventilation perfusion imbalance and hypoxic drive to breathe aeb abnormal abg's, elevated rr, shallow respirations, i>e, periods of apnea of 5 second duraction, dyspnea at rest, verbalized difficulty breathing, pt request for inhaler, hypercapnia, hypercarbia, hypoxemia, nasal flaring during respiration, observation of pt engaging in pursed-lip breathing, supraclavicular retractions, and observation of accessory muscle use during inhalation. 2. deficient fluid volume r/t diuretic use, inadequate fluid intake, active fluid loss, and failure of regulatory mechanisms aeb change in mental state, bp lower than normal, alternating pulse pressure, poor skin turgor, dry oral mucosa, increased urine output, output exceeding intake, dry skin , increased urine cx, weakness, verbalized absence of thirst, fissured tongue, and low h&h.  3. imbalanced nutrition: less than body requirements r/t inability to digest food, lack of knowledge concerning daily requirements, dislike of dietary restrictions, absence of appetite, economic status, and limitations in physical ability aeb aversion to eating, body weight over 20% below the ibw, hyperactive bowel sounds, lack of interest in food, decrease in appetite, poor muscle tone, reported intake less than rda, and magenta-colored tongue lacking tastebuds, verbalized dislike of facility food, verbalized dislike of home meal arrangement, order in chart for cardiac dietary restrictions, high creatinine, increased rdw, low lymphocyte count, low h&h, low mchc, and low rbc anemia thank you for helping me with my care plan and clarifying these things for me. i can't find some of the stuff i need to know on the web or in my texts. it gets so confusing!

hi, i was wondering if somebody could help me with my care plan. i am having trouble interpreting the findings of the echo. my pt has a hx of htn but he is dehydrated and thus his bp is extremely low. he also has a hx of cad, chf, mi, aortic stenosis, copd, glaucoma. he is on o2 at home. here are the echo findings: 1. mild l. vent hypertrophy, normal l. vent size, moderate global hypokinesis, moderately reduced l. vent systolic function (estimated ejection fraction=35%. 2. normal l. atrial size 3. mild r. vent enlargement with normal r. vent systolic function. 4. mild r atrial enlargement. 5. normal aortic root 6. no pericardial effusion 7. sclerotic aortic valve, biprosthetic mitral valve, thickened tricuspid valve, thickened pulmonic valve. so, both ventricles are affected and the r. atrium is enlarged. does this indicate that the pt had r sided hf and l sided hf? also, did this l sided hf likely lead to the r vent enlargement? or vice versa? i know that l sided heart failure usually leads to right sided heart failure, but i don't understand why! i know that the hypertrophy resulted from prolonged htn, and i also know that the thickened valves is a result of cad. is this probably what led to hf? thank you so much!:loveya:

Oh yeah... I totally forgot that the RDW points to internal bleeding. That's strange, I don't know what could be causing this value. Do you think that it may be r/t malnutrition and dehydration? he was ordered 10mL NS q24h, do you think that he was ordered the 10mL NS to aid in improvement of his hydration status? Thank you! :up:

Well, He was admitted for dehydration and was later Dx'd with stage II chronic renal failure. I know that the side effects of several of the medications that he is on is anemia, and he is receiving a multivitamin because he is so malnourished. I also know that his RBC was low, his RDW was high, his absolute lymphocyte count was low, his MCHC was low, and his H&H was low. Yeah, I guess I could describe the inside of his mouth as magenta colored. The past few times that he has beeen to the hospital, he was admitted for dehydration or hypotension, but he has a Hx of HTN and takes medicine for it. He also has a Hx of colon cancer, but I feel like he is malnourished and dehydrated because he is not eating enough and drinking enough. Thank you for helping me!!

is there a distinction between a secondary medical Dx and a Dx secondary to another Dx?

Hi, I had a clinical the other day, and I noticed something strange when I was viewing my pt's mouth. I had never seen it before, although I have seen the tongue characteristic of anemia. This pt's oral mucosa was bright pink (very strange coloration). His tongue had longitudinal grooves in it (fissures) and his tongue was bubble-gum pink... almost like a hot pink. I know that findings associated with anemia and dehydration are often fissured, smooth tongue that is dark "beefy" red in coloration. Is it always beefy red, though? Futhermroe, Is there another condition in which the pt's mouth will appear bright pink with a fissured tongue? His tongue was not coated. The whole tongue was bubble-gum pink. The texture of his tongue reminded me of a piece of wood, and I could not see any taste buds. His lips and gingivae were the same way. I couldn't really evaluate his conjunctiva because he has open angle glaucoma and his conjunctiva and sclera were extremely dry and reddened. I had not given him his drops yet. Thank you for reading my question and attempting to help me!

I did read the progress notes, and the progress notes indicated that the pt is in stage II chronic renal failure. He is dehydrated and also malnourished. I thought it was odd that he was being prescribed a diuretic for his HTN even though he was Dx'd with dehydration. Does this strike anyone else as odd? Even if he was taking this at home, should it have been discontinued until his hydration status was stabilized? It just doesn't seem to me that the dehydration could be reversed if the pt is taking a diuretic. Plus, his 24h I&O was 750 cc and 4400 cc via foley. I did not hear crackles, but I heard rhonchi bilaterally. He is also being prescribed NS 10 mL Q24H. I know that this is an isotonic solution, so he is probably taking this for his dehydration. This probably also indicates that his e-lytes are proportionately balanced, right? This would also lead to an increase in BP secondary to increase in blood volume, though. He was not hypertensive while in the hospital, and his BP was 132/64, but he was AFib on the monitor. So, he is probably still taking the diuretic because the NS is compensating, but 10 mL q24h is not enough compensation, is it? Maybe he needs to increase his BP because this is a low value for him because his body has adjusted to the HTN and the HTN is his new WNL, right? His SaO2 high was 98% and the low was 95%. I know that I probably have some errors up there. Can you help me figure out how I am looking at the situation wrong? Thank you for helping me. So, do you think that maybe the dehydration caused the RF in this pt? would both of these still be the primary Dx with no secondary, and all of the chronic D/o's listed under chronic conditions? His HTN is a chronic condition and is not limited to this visit. I think that I forgot to include a few of the chronic conditions, also: CAD, angina, CHF ("Acute/chronic systolic"), chronic bronchitis, open angle glaucoma, cataracts, colon cancer, and GERD. Thank you so much for all of your help! This care plan is a real kicker, but I have learned a lot from my interaction with this pt. I also have another question I wanted to ask. I am going to post it in this message and I am also going to post it as a separate entry. This pt's oral mucosa was bright pink (very strange coloration). His tongue had longitudinal grooves in it (fissures) and his tongue was bubble-gum pink... almost like a hot pink. I know that findings associated with anemia and dehydration are often fissured, smooth tongue that is dark "beefy" red in coloration. Is there another condition in which the pt's mouth will appear bright pink with a fissured tongue? His tongue was not coated. The whole tongue was bubble-gum pink. The texture of his tongue reminded me of a piece of wood, and I could not see any taste buds. His lips and gingivae were the same way. I couldn't really evaluate his conjunctiva because he has open angle glaucoma and his conjunctiva and sclera were extremely dry and reddened. Thank you so much for your help! Thank you for guiding me in this assessment.

Oh okay... well, would the secondary be renal failure? Lab tests later confirmed that the pt had renal failure, but can't renal failure be caused by dehydration? Thank you for helping me!!!

Hi, I am working on my care plan and I have never had a patient with a secondary medical diagnosis. However, the patient I was just assigned to care for does, and the link between the primary and secondary medical diagnosis is a clean picture. I hope that I am doing this right! He was admitted for dehydration, and the doctor later confirmed that he did in fact have stage 2 renal failure. He also had CAD, HTN, COPD, colon cancer, CHF, and glaucoma. I was just wondering if I am doing this right: I think that the Primary med. Dx is stage 2 renal failure. I think that the secondary diagnosis is dehydration. I think that the chronic illnesses are the CAD, COPD, colon cancer, HTN, CHF, and glaucoma. Am I doing this right? Thank you for taking the time to read my entry and try to help me. Have a great day!!!

Thanks, by the way. That really helped me a lot. I get it now. Maybe I was getting into depth a little...

Hi, yeah, I mean that her pulse had an irregular rhythm, but that the irregularity did not have a pattern. Like, instead of a pause in between every fourth beat, there would be a pause after the 4th beat, then after the 11th beat, then after the 14th, then after the 24th, then not again until after the 43rd, etc. Sorry, I may have used the wrong terminology. If so, what should I have called this?

Hi, my pt has a Hx of GERD:eek:, and he is being prescribed Protonix for management of his GERD. However, now he is NPO:yawn: because of diverticulosis. The only thing he can take po is his meds and a little H2O when he takes his meds. I was wondering if he would still need his PPI even though he is NPO and there would probably be no need for it (right?). :heartbeat

Hi, I was wondering if somebody could help me. I don't know how to document this injury. The man fell at home and nobody found him for 3 days, and he just laid there until finally his daughter found him. He has a purple area over his sacrum where he fell and he says that it is painful. Now, could this be a bruise from where he fell since he was laying here and this is where he landed when he fell, could this be a broken coccyx from how he landed, or could this be a pressure ulcer? I was thinking that it is not a pressure ulcer since he says that it is painful and he landed on this region, and you can't really say that it's a break, and to document it as ecchymosis would not be enough information, so should I have documented it as discolored area with pain upon palpation? Thank you!