nicolep13

Hey- Thanks for the input.. The thing is, our instructor gave let us look at the pt. chart and get as much info as we could- I haven't had a chance to actually assess her. She wants us to make a care plan from a diagnosis that she gave us. Mine happend to be A-Fib. I know very little about her- I know she is an assist X2 with all transfers, and I know that she is on cumadin. 3.5 mg M,W,F and 3 mg. Sun, Tu, Th, Sat. Her chart was very unorganized with info all over the place, the fact that I have never read a pt chart before didn't help, but I only had about a half an hour to get as much info as I could. My instructor did say though that the r/t could be a medical dx. But now I am back to square one with the dx. Crap!!!! It is hard to do this without really knowing anything about the pt. Thanks for your help though :) Nicole

Hey guys.. ok, I could really use some help on this whole care plan thing. This is my first care plan and I am STUCK!!! My mind is not allowing me to keep anything simple here and I think I am complicating things for myself. OK- here's the run down, What do you all think??? - 80 yr. old female - Dx of A-Fib, and Chronic Pulmonary Embolism - weakness - Dizziness -confusion Suffered from a concussion last month from a fall.. her sister said "She said she was weak and dizzy" Ok- weak,dizzy, and confusion are S/S of A-Fib- well CPE can cause A-Fib.. my mind wants to tie all that info into my nursing dx. Anyways- I know I can't use both A-Fib and CPE so here is what I have come up with: Decreased Cardiac Output r/t A-Fib AMB dizziness, weakness and confusion. And as far as goals.. Im stuck on that too.. but interventions I was thinking along the lines of keeping the HOB elevated @ 45 to help with maximum lung expansion and comfort, pt. teaching on caffine, and controlled breathing techniques. Lord have mercy- I know I sound like a mess.. I am all over the place here- What do you all think???? PLEASE HELP- Any input is so greatly appreciated!!!!! NICOLE

Hey thanks so much to both of you.. NurseAdida--I knew that I couldn't use the medical dx, but I just wasn't sure on how to rephrase them so that it would be a nursing dx. But I see what you are saying- so you can't have both the problem and etiology as a med. dx?? Like I can't have both the A-Fib and CPE in the statement (as problem and etiology) even if I re-word them right? See for some reason, my mind wants to tie in that the CPE is the cause of the A-Fib, but I guess I don't have to put that in there. LOL.. I think my mind is just on overload at this point. Ok- so I think I am going to use "Decreased Cardiac Output r/t A-Fib AMB dizziness and weakness upon standing. Which is saying that the A-Fib is causing a decrease in Cardiac Output which is making her dizzy and weak when she stands up. Sorry I am trying to make sure I got this. Anyways THANK YOU soooo much!!! I appreciate it GREATLY!! Nicole:yeah:

Hey!! I am in my first semester and doing my first care plan. I am totally stuck on how to write this thing. My diagnosis that I had to research is Atrial Fibrillation. My patient has chronic pulmonary embolism which is r/t A-Fib and has been expierencing weakness and dizziness. I need to come up with a nursing dx for this. I was thinking: A-Fib r/t Chronic Pulmonary Embolism AMB dizziness and weakness... or would it be Pulmonary Embolism r/t A-Fib AMB dizziness and weakness. I am so lost.. I know I can't actually use Pulmonary Embolism or A-Fib for the Problem part of the statement, but can't figure out a NANDA statement to use. I would soooo greatly appreciate it if someone could steer me in the right direction. Thank you so much.. Nicole:)