LexiStudent

Impaired gas exchange - He is on a vent, hemo/pneumothorax, abnormal abg's, smoker, scattered rhonci, decreased left lung base, rib fracture, and t3-t4 effects intercostal muscles. Ineffective airway clearance is likely the one you wanted me to use... Ineffective tissue perfusion - No, surprisingly the patient did not have any head injury which is why I am confused. Excess fluid volume - +2577, primary drip decreased from 150 to 50 mL/hr, decreased urinary output, 1+ edema, decreased hgb, hct, rbc Risk for peripheral neuromuscualr dysfunction - he was not able to move his hands prior to surgery, postoperatively he was able to and had sensation, more so on one side than the other. Impaired mobility - As far as mobility he is sedated and intubated. He has a lot of random movement in the legs and follows verbal command when asked to wiggle toes, push against hands, etc. He is currently dependent for all ADL's.

I have a patient that fell off of a roof and sustained a t3-t4 spinal fracture and multiple rib fractures as well as a hemo/pneumothorax. He has been sedated with ativan anf fentanyl since the accident. He had a thoracic spinal fusion since the accident. Upon assessment he opened his eyes to verbal stimulation. His pupils are equal, round and reactive to light. He has a normal heart rate and rhythm with capillary refill less than 3 seconds. His pulses are all all palpable (2+) and he has generalized edema 1+. He has scattered rhonci bilaterally and the left base is diminshed. He is on a vent with abnormal ABG's. Upon suctioning there is excessive bloody sputum. He has a productive cough and a chest tube draining a thick cherry color. He is NPO and has only has 12 hours of tube feed within the past 4 days. Prior to the thoracic fusion he was not moving or having sensation in his hands. Postoperatively he could not hold up just 2 fingers but he wiggle his fingers on both hands and had a strong grasp on one side and weak on the other. Lower extremities are fine. He has decreased rbc, hgb, hct, platelets, phosphate, and albumin. Increased AST. His fluid balance was +2577 for 24 hours. His meds include decadron (i do not know what this is for), nexium, acetaminophen, lidocaine, ativan\/fentanyl sedation drip. What do you think of these diagnoses. 1. Impaired gas exchange 2. Ineffective tissue perfusion (Cerebral) - my instructor told me to do this but i do not understand why and how or where to go with this. 3. Excess fluid volume 4. Risk for peripheral neuromuscular dysfunction 5. Moderate anxiety Thanks for any help...

Hello, I have a patient that I need 5 nursing diagnoses on. He came into the hospital with a fever and right upper quadrant pain. He was found to have kidney stones which made him septic. He went to a general floor but was then transferred to ICU when he went into respiratory distress/hypoxia and his blood pressures dropped into the 70's. He had an ERCP with papillotomy and stone extraction. He was vented for the surgery and it took him 2 days to wean. He was put on a 100% nonrebreather and then 3L nasal cannula; however, his O2 was dropping so he had to go back up to 5L NC with humidification. His abdomen was still severely distended. He also had a history of afib but was not in afib on the day of care and was put on amiodarone as well as heparin SubQ. Lastly, he had uncontrolled diabetes and stated that he couldn't afford insulin. I am going to do Deficient knowledge (diabetes) for sure. However, would decreased cardiac outout be acceptable? What about hyperthermia due to sepsis and increased temperature? Impaired gas exchange? Thanks!