MJ_14

Hey guys! His family was noncontributory, so I, too, was a little baffled with the patient teaching/knowledge deficit. It's hard to say what exactly he can and cannot understand since he cannot communicate with me, you know? His temp was taken in his ear and TDRF stands for tracheostomy-dependent respiratory failure, which was due to the subarachnoid hemorrhage from his fall. He is now back on a ventilator with full support. Since I couldn't exactly figure out why he would have a low temp, I went ahead with the impaired physical mobility as my last diagnosis. Any other questions or suggestions for me?

So, my patient was admitted for TDRF following a subarachnoid hemorrhage. He was found unconscious in his home after a fall. He has a medical history of schizophrenia, bipolar disorder, chronic kidney disease, seizure, diabetes insipidus, subdural hematoma. Although he was admitted for TDRF, he is now on a ventilator with full support. He obviously still has a trach collar. He has a sacral wound and wounds on both heels, 1+ pitting edema in both feet, zero movement in both legs and right arm; left arm is the only one that moves, although it's very limited due to its contraction. He doesn't communicate, but can sometimes track you with his gaze. He was incontinent of bowel and had a condom cath. He also had a temp of 94.5 degrees. Hopefully, I didn't forget anything. We are to come up with 6 diagnoses, one being deficient knowledge r/t ----. Here'es what I've come up with so far: Ineffective airway clearance r/t presence of secretions AEB diminished breath sounds, inability to cough, dysphagia, purulent secretions on and around trach collar. Risk for aspiration r/t impaired swallowing, depressed cough, decreased LOC, weakened muscles. Impaired verbal communication r/t decreased cognitive function AEB disorientation to person, place, time, inability to follow verbal commands, dysphagia, muscle weakness, schizophrenia, bipolar disorder. Impaired skin integrity r/t prolonged bed rest AEB sacral wound, heel wounds, Z-Flo boots, Dolphin bed, Z-Flo positioner. I need one more diagnosis + the deficient knowledge (which I will figure out after reviewing my notes from the day). Here are my potentials: Ineffective Thermoregulation r/t decreased amount of subcutaneous fat OR decreased hypothalamic function secondary to brain injury?? AEB low temp of 94.5. Impaired physical mobility r/t decreased LOC AEB brain trauma, passive ROM, inability to bear weight. What do you guys think thus far and what would you suggest? Any help is appreciated!

Haha! Thanks guys! GrnTea, I agree about the r/t, AEB usage! It can be very confusing. As for the "MBSS", that's a Modified Barium Swallow Study to assess for aspirations. Thanks for the help, it will most definitely be used! :w00t:

My patient's current condition that I'm using for my skeleton map is cardiomyopathy. It was noted that he has severe hypokinesis of the apex, an EF of 30-40 %, an elevated HR, etc. I have to come up with 5 diagnoses related to his condition. Here's what I've come up with. Decreased cardiac output r/t altered heart rate and rhythm AEB atrial fibrilation, anteroseptal infarction, marked ST abnormality, left axis deviation, HR of 128, shortness of breath, EF of 30-40%, hypokinesis of the apex, and weakened pulses. Ineffective breathing pattern r/t ? AEB use of accessory muscles, shortness of breath, RR of 48. Ineffective airway clearance r/t presence of secretions? AEB diminished breath sounds of the left side, crackles on the right side, productive cough, thick sputum, severe aspirations on MBSS. Impaired verbal communication r/t decreased cognitive functioning AEB drowsiness, difficulty speaking, unorientation to person, place, time. Am I on the right track here? For some reason, I'm struggling. These obviously need work and I still need one more, but suggestions are appreciated!

I'm with Ashley. Well said girlfriend.

What would you say were the top 3 problems for my pt? He is also cachexic so I'd say that would be one of three. Impaired gas exchange would be another guess... and deficient fluid volume to the bowel obstruction.

Thank you so much, both of you! That was a tremendous help! I figured I should go with lab results related to the bowel obstruction, but the diagnosis of VDRF even when they are off of the vent always throws me for a loop! Again, thank you guys so much!

Okay so... I received a new patient today for tomorrow's clinical and he was admitted with VDRF secondary to a bowel obstruction that was caused by an incarcerated hernia. He actually also has a history of sigmoid volvulus which also lead to bowel obstruction two years prior. I am to find a correlation with the pathophysiology/lab & test results. Would you suspect that I am comparing the VDRF, alone, with lab results? Background info for you: He has actually been weaned from the vent and now has a trache collar. He has both a Passy Muir and cap for his trache... (hopefully that's how you would word that). I guess what I'm trying to figure out is what am I trying to correlate here? Any suggestions?

This very thing happened to me last week as I started my first clinical day! Monday night I stayed up to preplan and was so nervous about the next morning that I, too, only got an hour of sleep. I was SO exhausted, but once I got to the hospital it was like all the exhaustion just magically disappeared. I was alert and attentive and never even thought about sleep again until the second I walked out of the hospital doors! I'm so thankful that it happened that way, but I'm also hoping, like you, that it won't happen again! My advice for you, based on my own experience is to try to have everything done the night before as soon as possible... that way you can at least get in bed at a decent hour even if you are still anxious. It may sound cheesy, but I have to listen to music to put me to sleep sometimes. Not only does it contribute to how fast I fall asleep, it also relaxes me as long as I choose slower-paced songs to listen to. Try classical music maybe!? I like to listen to classical music when I study and right before tests because it seems to help my test anxiety. I've found that it helps me sleep some nights as well. Don't worry about missing the first day.. you did the right thing by not putting your patient in harm! It's now over and done with so don't let it hold you back! I find myself dwelling on things like this, but you have to keep your chin up and keep pushing! I'm a first year student as well so we can keep each other going!:hug:Hopefully, you have gotten tons of tips from our posts and will be able to relieve some of that anxiety! Good luck on your next day!

Thank you so much for your input! I still have trouble leaving out the obvious and finding what's really important so I'm working on that! As for the catheter evidence... we were told to list as much evidence as we could so I was sort of reaching for anything I could think of that may count as "evidence" of elimination problems. Making diagnoses seems so easy, but once I start writing it's actually more challenging than it appears. Hopefully I'm not totally off for my first care plan.

My pt is, indeed, very sick. The hospital that my clinical group got assigned to is a long-term acute care hospital with about 22 patients total who are all extremely sick with long lists of diseases/disorders. I saw him on Tuesday and two days later, Thursday, he was d/c to a SNF. That's how bad it is. Can you imagine your first clinical experience being as such? I'm thankful that I will come out of this with tons of experience and knowledge, but it is quite challenging! :) As for the diagnoses, I actually used a care planning book and added my evidence. Thanks for your input! I am working on making these changes today and will hopefully be able to use your advice! Do you have a more specific suggestion for the "impaired urinary elimination" diagnosis? I'm wondering if I should just replace it with a totally different diagnosis. Thanks again for your help, I was worried I wouldn't get any feedback!

It's an actual drug guide, probably similar to what you use. Here's a link with lots of resources and although it's for Davis's, it may still be helpful. I'm not sure if they have printable drug cards, but I know there are "flash cards" you can use to review via the web. This may or may not help you, but I have found it useful. We have to hand write a set of drug cards every couple of weeks for my Pharm class and boy, are they tedious!? Anywho, here's the link -- hope it helps: DrugGuide.com | Davis's Drug Guide Online + Mobile -Maggie

Hi Mary, Do you have a copy of Davis's Drug Guide for Nurses?

Hey guys, I am currently working on my first care plan for my recent clinical. I had to come up with 5 nursing diagnoses and have to put them in order from most important to least. Here's what I've come up with.. just need some suggestions on the order of importance. Any opinions are greatly appreciated. If you see errors in my actual diagnosis, please let me know! These are not in any particular order yet, by the way. Impaired swallowing r/t weakness of the swallowing muscles and diminished or absent swallowing reflex/gag reflex AEB severe aspirations on MBSS, dysphagia. Impaired skin integrity r/t immobility, bed rest AEB disruption of epidermal tissue, pressure ulcers, saccral/heel wounds. Decreased cardiac output r/t changes in myocardial contractility AEB occasional PVCs, sinus tachycardia, left axis deviation, anterior infarct. Ineffective airway clearance r/t increased production of bronchial secretions AEB wheezing, RR 22, yellowish to brown secretions. Impaired urinary elimination r/t obstruction of enlarged prostate gland AEB urinary catheter, UTI symptoms. What do y'all think? Terrible? :thankya: