DSCCnsg14

I need a quick lesson on what pathophysiology is, how to write up a patho on a diagnosis (ie. hypertension), and how to pull information out in a summarized form? I am very lost; a patho book was not required for this semesters course so I feel left in the dark.

[TABLE] [TR] [TD]Creatinine [/TD] [TD]0.8 – 1.3 [/TD] [TD]3.8 MG/L [/TD] [TD]H [/TD] [/TR] [TR] [TD]BUN [/TD] [TD]7 – 18 [/TD] [TD]42 MG/L [/TD] [TD]H [/TD] [/TR] [TR] [TD]Glucose [/TD] [TD]74 – 106 [/TD] [TD]153 MG/L [/TD] [TD]H [/TD] [/TR] [/TABLE] [TABLE=width: 813] [TR] [TD=colspan: 5]Capillary refill: [/TD] [TD=colspan: 3] [/TD] [TD=colspan: 3]X [/TD] [TD=colspan: 3] > 3 sec. [/TD] [TD=colspan: 3] [/TD] [TD=colspan: 7] [/TD] [/TR] [TR] [TD]Skin: [/TD] [TD=colspan: 2]Color: [/TD] [TD=colspan: 6]Appropriate for race [/TD] [TD=colspan: 3]Temp: [/TD] [TD=colspan: 6]Warm to touch [/TD] [TD=colspan: 2]Turgor: [/TD] [TD=colspan: 3]Recoil > 4 seconds [/TD] [TD] [/TD] [/TR] [TR] [TD=colspan: 6] Mucous membranes: [/TD] [TD] [/TD] [TD=colspan: 3]Color [/TD] [TD=colspan: 5]Pink - yellow [/TD] [TD=colspan: 4] Lips: [/TD] [TD=colspan: 3]Color [/TD] [TD]Appropriate for race [/TD] [TD] [/TD] [/TR] [TR] [TD=colspan: 2]Edema: [/TD] [TD=colspan: 2]Present [/TD] [TD=colspan: 6] [/TD] [TD=colspan: 3]Absent [/TD] [TD=colspan: 3] X [/TD] [TD=colspan: 5] [/TD] [TD=colspan: 3] [/TD] [/TR] [/TABLE] [TABLE=width: 813] [TR] [TD] Rate: [/TD] [TD=colspan: 2]RR 16 [/TD] [TD=colspan: 2]Rhythm: [/TD] [TD=colspan: 3]Regular [/TD] [TD]Character: [/TD] [TD=colspan: 4]Unlabored [/TD] [/TR] [TR] [TD=colspan: 2] Breath Sounds: [/TD] [TD=colspan: 2] Clear [/TD] [TD=colspan: 2] X [/TD] [TD]Wheeze [/TD] [TD] [/TD] [TD=colspan: 2]Crackles/rales [/TD] [TD] [/TD] [TD]Rhonchi [/TD] [TD] [/TD] [/TR] [/TABLE] [TABLE=width: 813] [TR] [TD=colspan: 3] Urinary Pattern: [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 3] Several times through [/TD] [TD=colspan: 2] out the [/TD] [TD=colspan: 2] day [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 2] [/TD] [/TR] [TR] [TD=colspan: 2] Nocturia: [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 3] X [/TD] [TD=colspan: 2]Pain: [/TD] [TD=colspan: 2]Denies [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 2]Incontinence: [/TD] [TD=colspan: 2]Denies [/TD] [TD] [/TD] [/TR] [TR] [TD=colspan: 2] Retention: [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 3]Denies [/TD] [TD=colspan: 2]Frequency: [/TD] [TD=colspan: 2]5x daily [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 2]Burning: [/TD] [TD=colspan: 2]Denies [/TD] [TD] [/TD] [/TR] [TR] [TD=colspan: 2] Blood: [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 3]Denies [/TD] [TD=colspan: 2]Distention: [/TD] [TD=colspan: 2]N/A [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 2] [/TD] [TD] [/TD] [/TR] [TR] [TD][/TD] [TD=colspan: 5][/TD] [TD][/TD] [TD=colspan: 2][/TD] [TD=colspan: 2][/TD] [TD=colspan: 2][/TD] [TD=colspan: 2][/TD] [TD=colspan: 2][/TD] [TD][/TD] [/TR] [/TABLE] [TABLE=width: 813] [TR] [TD=colspan: 3] Eating habits: [/TD] [TD=colspan: 3]3 [/TD] [TD]meal [/TD] [TD=colspan: 2]s daily [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 3] [/TD] [TD] [/TD] [TD=colspan: 2] [/TD] [/TR] [TR] [TD=colspan: 8] Food preferences/Intolerances: [/TD] [TD=colspan: 3]Likes: bake [/TD] [TD=colspan: 2]d be [/TD] [TD=colspan: 2]dns, potato [/TD] [TD=colspan: 2]salad, and chopp [/TD] [TD=colspan: 3]ed BB [/TD] [TD]Q; no d [/TD] [TD=colspan: 2]islikes. [/TD] [/TR] [TR] [TD=colspan: 5] Fluid/food intake: [/TD] [TD=colspan: 6]75% total daily fluid intak [/TD] [TD=colspan: 2]e an [/TD] [TD=colspan: 2]d 100% tot [/TD] [TD=colspan: 2]al daily food inta [/TD] [TD=colspan: 3]ke. [/TD] [TD] [/TD] [TD=colspan: 2] [/TD] [/TR] [TR] [TD=colspan: 5] [/TD] [TD=colspan: 6] [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 3] [/TD] [TD] [/TD] [TD=colspan: 2] [/TD] [/TR] [TR] [TD=colspan: 2] Current diet: [/TD] [TD=colspan: 9]ADA, thin liquid consistency [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 2] [/TD] [TD=colspan: 3] [/TD] [TD] [/TD] [TD=colspan: 2] [/TD] [/TR] [TR] [TD=colspan: 2] Dentures: [/TD] [TD=colspan: 8]N/A [/TD] [TD=colspan: 2]Nausea: [/TD] [TD=colspan: 4]Denies [/TD] [TD=colspan: 2]Vomiting: [/TD] [TD=colspan: 3]Denies [/TD] [TD=colspan: 2] [/TD] [/TR] [TR] [TD=colspan: 4] Current weight: [/TD] [TD=colspan: 6]200 lbs. [/TD] [TD=colspan: 4]Current height: [/TD] [TD=colspan: 2]66” [/TD] [TD=colspan: 3]Weight change: [/TD] [TD=colspan: 3]Weight ↑ [/TD] [TD] [/TD] [/TR] [TR] [TD]Comments: [/TD] [TD=colspan: 9]Patient eats independently; [/TD] [TD=colspan: 2]no supple [/TD] [TD=colspan: 4]ments; no added salt; n [/TD] [TD=colspan: 2]o fried food [/TD] [TD=colspan: 3]s. Weight ↑ [/TD] [TD=colspan: 2]of lbs. [/TD] [/TR] [TR] [TD=colspan: 4]since 07-25-12; n [/TD] [TD=colspan: 6]o difficulty chewing. [/TD] [TD=colspan: 2]Patient d [/TD] [TD=colspan: 4]enies any N/V but PRN [/TD] [TD=colspan: 2]meds [/TD] [TD=colspan: 3] [/TD] [TD=colspan: 2] [/TD] [/TR] [/TABLE]

The careplan I am having to complete is for an ESRD patient. She just underwent hemodialysis catheter placement surgery two weeks ago. I am in need of help regarding the "planning" and "interventions" section of my care plan. Does anyone have any good NANDA information.

As for the assessment information, (instructor likes using arrows) how do you determine ALL the subjective and objective data. Increased uncleanliness would include is untidy apartment with beer bottles everywhere. For decreased orientation would I need to include (x2) for place and time? Subj: no alcohol abuse, ↑ hallucinations, ↑ agitiation, ↓ social interaction. Obj: 60-year-old male, ↑ uncleanliness, ↓ attention, ↓ orientation

After you explained NANDA and the differences between nursing diagnosis and medical diagnosis REALLY helps me where to start my nursing care of plan. The scenerio really caught me off guard when there was no vital signs or other important physcial assessment information.

We are in the same group :) Thank you so much, going into this completely blind and now to have a grasp on it - Thank you!

thank you:)

I have an EXTREMELY picky instructor who teaches my ASN class as an MSN course (she just graduated and we are her first class to teach). With this being said, I am TERRIFIED to turn in my nursing plan of care which was a group assignment - my entire group has this mutual feeling. My teammates and I chose "Acute confusion r/t acoholism as evidence by pacing, wringing of hands, disoriented x3, hallucinations, inattentiveness, denial of alcohol abuse, and beer bottles throughout apartment" Here is the scenerio: David Micheals lives in an urban senior citizens' apartment complex. He is a 60 year old widower and retired military man with two adult sons whom he says rarely visit. He has been referred to your hospital-based home care unit for follow-up after inpatient treatment from acute pancreatitis. He has been hospitalized three times in 6mons for this diagnosis and denies excessive alcohol use. He says, "I have a few beers every now and then, nothing I cannot handle." You have seen Mr. Micheals on a weekly basis for the past month. He has stated he doesn't know any of his neighbors and never sees his boys. "They never come to see me anymore." He is pleasant, cooperative, and oriented when you see him and always thinks you for coming to visit. His two-room apartment is usually untidy, but clean, with dishes and glasses in the sink and several plastic trash bags in the kitchen. Today, when you arrive, Robert, his oldest son, is present and looks angry when you introduce yourself. He tells you Mr. Micheals has always been a drinker, but in the past year or so things have gotten out of hand. "We don't let our kids come over here; we never know what he'll be like. I've tried to get him help, but he won't listen to me. I can't take it anymore." Mr. Micheals is in his bedroom, yelling at and calling for David. When you enter the room, he is pacing, wringing his hands, and is unable to identify you. He is disoriented to place and time and tell yous "don't step on them bugs" pointing to the patterned rug. He is inattentive when you ask questions about his condition and continues to pace. There are numerous empty beer bottles throughout his apartment. Mr. Michea;s becomes increasingly agitated and his son abruptly leaves. After checking his vital signs you notify his physician and arrangements are made to transport him to the hospital. Mr. Micheals is seen in the ER and is admitted to the psychiatric unit for detoxification and treatment. *** I have attached our classes care plan instructions and my groups care plan

During my clinicals on Tuesday, I had to perform my first head-to-toe assessment. I have to complete our "Adult Health Assessment" form which is due by Tuesday (10-16-12). There is three pages of information that I am just stressing on. For the following what are some ways that you described or worded for your health assessments in the past: 1.) exercise habits: 2.) sleep - hours: 3.) sleep - naps: 4.) sleep - aids (meds/pillows/food): 5.) ADLs if patient was dependent 6.) circulatory comments: 7.) respiratory comments: 8.) bowel pattern: 9.) bowel elimination comments: 10.) urinary pattern: 11.) urinary comments: 12.)genitalia comments: 13.) neurosensory comments: 14.) eye and ear comments: 15.) nutrition comments: 16.) environment: 17.) skin integrity: 18.) psychosocial history: 19.) educational needs: 20.) pain assessment: I have a VERY tough teacher that just does not seem to be happy with anything. She recently graduated with a Master's; my class is her first class she has taught. She treats us like we must know EVERYTHING and not first semester nursing students.