Guest 360983

A nurse who is much smarter than me told me that the elderly are like babies--neither group compensates well and both have initial presentations that are very different from the healthy young adult. If you had a neonate who was hypothermic, hypotensive, tachycardic, tachypenic and inconsolably fussy, what would you be concerned about? You need the NANDA book, not a care plan book. Look on Amazon or in GrnTea's posts for the exact name. Look at the defining characteristics for each diagnosis to make sure you have the appropriate one selected. Always prioritize based on Maslow's pyramid. Your priority should be things that can kill the patient. I would also recommend looking at SIRS criteria.

Ischemia takes hours to show up after the initial infarct. The initial CT may show no abnormalities.

I want others to explain. I'm that annoying nurse who asks students for rationale.

Why are we doing the labs ya'll suggested?

That's a fairly tough assignment for a pre nursing student. When you mention a nurse cleaning wounds as a provider, I think you're on track. To me, providers do stuff. Nurses do a variety of things, from cleaning wounds to assessing patients to administering medications. To me, managers coordinate work and divide it up. A manager in an office may keep track of the progress of all her subordinate's projects and make sure the projects are done correctly. The manager may decide who does a particular presentation. The manager may make sure two departments work together. Your definition mentions delegation. How and what and to whom do you think nurses delegate? Your definition mentions groups of patients. What do you know about nursing with large groups of patients? A RN in the community or in a skilled nursing facility will have a large group of patients and must utilize different skills than the nurse in the hospital who acts more as a provider.

My initial instinct is yes, but what's preventing management from slowly inching back to the (sub) standard conditions?

Good! Now grab your NANDA book and make sure your diagnoses are in it. I know risk for PE isn't one. I imagine there's a nursing way to say it. Make sure to look at the defining characteristics for the diagnoses so you can determine if they are the most appropriate ones. Why did you get rid of the impaired perfusion?

Use Maslow's hierarchy to help you prioritize. In the ER you get the highest priority if you have a life or limb threat. EDIT: I think you're missing some important risk diagnoses. I don't have a NANDA book handy but what are the defining characteristics for impaired mobility? Are you concerned about impaired mobility because of the effect it's having on ADLs or is there something deeper going on?

I don't chart care plans. I chart my initial assessment, reassessments per floor policy, reassessments when change in condition is noted, interventions and discharge instructions. This could be simple and fast on a benign belly pain or one nurse's sole job on a crashing patient.

Tell me about what you think of when you read provider. Next, tell me what you think of when you read manager. Seriously, write this down before you go futher. Now think about what you have seen nurses do in clinicals and what you've learned about nursing. What actions match your provider definition? What actions go with your manager description? I will defer to others on the profession question.

I'm lazy so I count the number of complete QRS complexes in a 6 second strip and multiply by 10. You can measure the number of large boxes between the same part of consecutive complexes (say between the start of one P and the start of the next P) and divide that number by 300. You can also measure the number of small boxes as I just described and divide that number by 1500.

So this might be part of the care plan :)

What did your assessment show? What did the nurse spend most of her time doing with the patient? Why is the patient hospitalized and not getting antibiotics via PICC at home?

If you like sick kiddos, don't underestimate the value of an ICU or ER rotation. The ER sees every age group, including pediatrics (unless you have a children's hospital in the area, which I doubt because of the lack of NICUs). The ICU will teach you about vents and drips and how to do a thorough, focused assessment. You don't have to like your placement, you just have to learn. Don't do nursery unless you're interested in L&D. In my not very progessive state, most hospitals have closed their nurseries in favor of couplet care. If you want to do L&D, great (someone needs to do it because I sure as hell don't! ), but otherwise you're not going to get a ton of transferable skills like you would on other units. Do medical peds and general peds. Put general peds first if you would rather work there. Capstone is a semester long interview and ideally you want to do it on a floor you want to work on. Seriously consider ICU if you want to do sick kids or ER if you want to do general kids. I promise the ER won't be boring and you'll learn things like septic workups on neonates, how to swab a cranky toddler's throat for strep, and why we give PCP (ketamine) to kids for sedation.

When my MIL had cardiac surgery, the hospital she was in had a cardiac surgery ICU and a separate cardiac ICU. One took all the surgical patients (CABG, valve replacements) and the other took nonsurgical patients (MI, CHF). And that's not counting the transplants, who were on a separate floor!

I'm an ER nurse, not an OB nurse. I have a few accidental catches and several late miscarriages under my belt, however. I would be VERY concerned about hypotension in a postpartum mom as she should be able to compensate for a typical amount of blood loss. People can bleed quite a bit before they decompensate, which is why as nurses we are always looking for early signs that something is amiss. EDIT: To me, hypotension to worry about is usually a trend downwards over time, a MAP in the low 70s (MAP of 65 is bolus and presser time) or a systolic below 90. Of course, if the patient is old and/or has underlying hypertension, I adjust upwards. I also have cardiac monitoring, vasoactive drugs and MDs at my fingertips.

I think you're doing a fantastic job with this case. He may well have only vomited once, especially with the NSAID use. Most of the Mallory Weiss tears I've seen as a ER nurse have been in pregnant women with hyperemesis--I share this as a reference point, not as an exclusive situation. When I say stress response, I mean physical stress on the body that results in inflammatory processes. That's the bit with cytokines and such that someone much smarter than me explained up thread. Make sure you can back up anything you put in your care plan. Your professor probably won't like gastritis with one episode of vomiting (not the typical presentation).

His WBC was likely elevated from gastritis (vomiting that causes a tear is rarely a one time thing) and/or stress response/inflammatory changes from the body reparing the tear. It's not the bleed so much as the cause of the bleed. GI bleeders run the gamut from your patient to ruptured esophageal varacies. The more you can figure out about any patient's true underlying pathophysiology, the better you can tailor their care.

What are you concerned about in the postpartum patient? What assessment findings are consistent with this concern? How do those assessment findings compare to the information provided in the question? 110/60 is a typical BP for a young, healthy patient, which most OB patients are.

I know this is probably late but for future students: So tell us more about your patient. I see he is diaphoretic, tachycardic and tachypenic. What did your abdominal assessment reveal? What did the rest of your skin assessment show? What were his lab results, especially his lactate? What did imaging show beyond the microperf? What is his plan of care? What do his stools look like beyond loose? What are his comorbidities? What are his vitals? Psin sucks but will not kill the patient the way sepsis can.

How is her interaction with baby? How is her interaction with family?

A doc once told me viral illnesses raise WBCs higher than most bacterial infections. I don't have any evidence for this, so take it with a grain (or a shaker) of salt. Like Esme said, don't underestimate the body's stress response.

I think you need to shadow some nurses and midlevels in the ER. Even at the busy trauma hospitals, trauma is VERY far from the majority of patients. I've heard the busiest trauma ER in the country is 20% trauma--more on weekend nights, less on Wednesday at 8 am. I miss my trauma experience but I'll tell you the sickest ones were out of the department and into the OR so fast your head would spin. You'll spend far more time with septic nursing home patients and drunks who choose the hospital vs jail when asked by the cops. You should also ride on an ambulance. If you see yourself as a trauma junkie, it might be an option for you. Plenty of people use 911 as a cab, but paramedics really do see it all. Don't get me wrong. I love being an ER nurse and wouldn't be a doctor or an NP or work on a different floor for anything, but my job is way less sexy than it looks on TV.

In the two hospitals I've worked at, the NPs and PAs are used the same. At the trauma center, the midlevels weren't allowed out of urgent care. At the community hospital, they see non dying patients first to order the labs and meds. They also do some procedures (I&D, suturing) when the docs are busy but usually the docs like to do procedures so they can bill for them. If you want to be on the front line of trauma, become either a paramedic or an ER physician. I would be surprised to see midlevels at any hospital handle traumas because the level 1 trauma centers tend to be teaching facilities and the residents need to learn how to handle trauma. I know Acute Care NPs can do central lines and intubate but that's because (in my area anyways) they are trained to cover the ICU at night when there is no physician. All ER NPs I've met have been family practice NPs, who definitely are not trained for those procedures.

New York City Severe Sepsis Project I'm assuming you are in the ICU based on previous posts? I used this site to help revamp our ER sepsis screening protocol. Definitely check out the Surviving Sepsis campaign. Also, check out the recently publishef ProCESS study, which showed that the Rivers bundle isn't superior to aggressive non - invasive management. Be careful because "usual care" in the ProCESS study isn't universal--my hospital even now doesn't routinely do all those things (even the initial 2 L can be a stretch) so there is still definitely a place for good protocols. We just don't necessarily need CVPs on everyone.