tulip5

So if I understand your current question(s). (1) Why am I adamant his priority problem is dehydration? The answer is: fluid imbalance (current... not risk for) always ranks everything else except issues of oxygenation. End of story. Is your instructor asking you to justify your nursing diagnosis? If so, that's the answer. (2) Why is pain not up there as a top priority? Because it won't kill him. Also because with a clouded sensorium we really don't know what his subjective experience is. It's tough to know. First... I don't want to treat what I can't assess and second... he is so unstable I don't want to push much opiate just this minute. (3) Is your instructor asking you WHY the pt. is dehydrated? Because he's so hyperglycemic, his renal threshold has been exceeded, he's loosing lots of glucose into the filtrate, and it's dragging water with it. (Osmotic diuresis.) (4) Pre-operatively, it would have been insane to operate on the guy in this condition. (Nothing will heal when there is hyperglycemia) and his graft is going to fail because of the dehydration and other derangements. So I have to think, he became a metabolic mess post-operatively. (5) What is the source of the infection? Without further assessment, it's impossible to know. But, figuring it out would mean checking first his lungs (CXR, physical assessment) and then water (urinalysis) then wound (which will not be healing because of the hyperglycemia), then looking for DVT (and he's probably on heparin post-operatively to keep the graft from clotting off, so that's unlikely.) I'm thinking they were trying to revascularize the leg to save a foot which likely has infected bone in it or something and the osteo is distal to the graft. Bottom line (take it to the bank) your priority problem is fluid imbalance (dehydration). Your secondary problem is hyperkalemia but the correction of his high sugars will tank it, so you would just watch it as you gave insulin and normal saline. Your third problem is likely infection (which will make his sugars go way up due to stress hormone... cortisol) So insulin, saline, and antibiotic... prescribed by the MD, obviously.

When do you know if something is "proven"? What threshold of proof do you require?

What is "NS"?

Your priority is dehydration. Why? Because after oxygenation (which appears OK based upon the data you give) the next most important basic human need is fluid and electrolyte balance. You did not tell us what his serum chemistries are, but chances are very good the BUN and creatinine are quite elevated. His K+ is high because he's dehydrated, and thus he is not perfusing his kidneys well. Give him fluid replacement, the kidneys should kick in and the K+ will come down. BUT WATCH OUT!!! Are you going to give him insulin to treat his hyperglycemia? Insulin drives K+ into the intracellular space. If you aggressively and unwisely treated his hyperglycemia you could find your patient suddenly hypokalemic (and dead.) Dehydration (or more properly hyperosmolarity) is his priority problem because his level of consciousness is impaired. CNS neurons are telling you he has to be hydrated NOW. Some (probably not all but some) of his fever can be related to dehydration. More to the point, you don't know how much of the fever is true fever until his fluid imbalance is corrected. Fluid imbalance is your problem because he's got a fever and this drives his insensible fluid loss up, aggravating dehydration. If his output has been low and his blood sugar high, I'd worry about urosepsis. But you analyze fever in the following order: Wind (lungs), water (cystitis, pyelonephritis), wound, and "walking" (this relates to DVT but they had to have a "w" to keep the alliteration going). You didn't tell us what his chemistries are but (counterintuitively) his serum sodium is likely low. (You see this when there is hyperglycemia. The hypothalamus is telling the kidneys to dump sodium in a desperate attempt to correct the osmolality.) That is why the patient needs normal saline. He has lost sodium in excess of water. So... dehydration first. Potassium balance second (but not simply hyperkalemia. Beware sudden hypokalemia!)

Oh, actions... I think some of this takes adjustment of the analgesics. May need something with the opiate. NSAID (ketoralac if she's not bleeding) works GREAT. If she's on morphine, try equianalgesic dose of dilaudid. (different people do better with different opiate.) Did anyone look to see that the IV was patent? Maybe it's not getting in the vascular system.

Oh... likely nursing diagnosis: (depending upon exact assessment data) Impaired gas exchange RT respiratory depression (opiate/anesthetic) and splinting AEB (vital signs here), pt. not coughing deep breathing, c/o incisional pain, etc.

You've gotten some really good responses here, and I am just going to give you my simple-minded approach to the pretty-freshly-post-op patient. First of all, you must have a system for prioritizing your patient assessment and planning. Here is mine: (1) oxygenation (everything from drawing breath into the lungs, getting oxygen onto hemoglobin, pumping it to the body, etc.) (2) fluid and electrolytes (includes acid/base balance) (3) nutrition (4) elimination (do the bowels and bladder work?) (5) rest/restoration (pain and sleep) (6) mobility (7) homeostasis (clotting cascade, immune system, cortical... i.e., brain.. function, special senses, etc.) Nothing authoritative about it. It's just a system that works for me. Let's apply it to your patient. Oxygenation: Your patient had general anesthesia 24 hours ago and that stuff can hang around a while. (I like to know how long my patients were under.) But most of all, she's been hitting the PCA pump pretty heavy. You don't tell us what the settings were, but let's say it was a generous amount. I would ABSOLUTELY make sure she is on a pulse ox, and I'd spend a bit of time doing a thorough pulmonary assessment on her. In my experience, patients can have a lot of respiratory depression during this time. Not to mention, she's had her breast cut off and the flap messed with and since she's not getting good pain relief... she is almost surely splinting and hypoventilating. Under this category, I'd also be looking at how much blood is coming out of her drains and what her most recent Hct/Hgb is. I always look at the Op-report and get the EBL (estimated blood loss) number and if any blood was administered. Fluid and electrolytes: Several people have mentioned that this output (30-50 ml/hour) is reasonable. Yes, I would likely agree. Patients after surgery tend to third-space and they get behind (intake more than output) for a day or two until they have a big diuresis. I wouldn't sweat this relatively low output... I'd just keep an eye on fluid balance (which means measure INTAKE AND OUTPUT.) Nutrition: Wouldn't worry about it a lot 24 hours out. I would note, however, if she's having any nausea or vomiting. Elimination: Too soon to worry about any lack of BM's, and she's got a foley. However, opiates, poor food intake, immobility will all lock her up, so she should be on a stool softener. SCIP protocols require the foley come out by 48 hours. Rest and restoration: If we aren't managing her pain, she won't heal, she won't sleep (honest complete-sleep-cycle healing-kind-of sleep), she won't eat, she won't mobilize. (Tomorrow the foley will be out and she'll HAVE to get up.) Mobility: (see above) Physiological homeostasis: Are the opiates causing orthostatic hypotension? Are her vitals stable? What's her white count and does she have a fever? If the original dressing is still on, you'll probably not be assessing the wound today. I'm assuming that she's AAOx4 (when you can rouse her out of her opiate lethargy.) So if your faculty want you to identify a priority need, and they tell you the patient is hitting the PCA w/out getting relief, I would tell them nothing happens until I know she's breathing great and oxygenating like an 18 year old athlete after a 100 yard dash!

Ya know what... there are people walking around who have AAA's and don't know it. There are others that know it and are just being monitored... to make sure it doesn't get any worse. And then there are those that are burst and you have WWIII on your hands and the issue is hypovolemic shock. Makes me crazy when faculty ask students to pull nursing diagnoses, outcomes, actions, and evaluations out of thin air with no assessment data. But here is a possible avenue for you to go. What causes vascular wall damage? Do you know about the Law of LaPlace and that even teeny increases in the diameter of the aneurysm can make its rate of expansion increase? So, you'd want to think about (maybe) blood pressure control.

I agree with LauRN. In addition, as you're learning about clinical reasoning... always remember that "RT" (related to) requires that you address causality. I have students who will write a dx like "Knowledge deficit RT coumadin AEB taking drug incorrectly and with aspirin." I always ask the students... Did the coumadin actually suck knowledge out of the patient's head? Of course not. The correct answer would have been "Knowledge deficit RT inadequate patient teaching during previous admission AEB (etc. etc.) ALso, there is a problem with NANDA's with regard to your patient. There is "Risk for infection"... but look through all 216 diagnoses and you won't find "infection". That may be why you're struggling. Thus, LauRN is absolutely correct. The reason your patient was readmitted with a post-op wound infection is that you have a "risk for" situation.

I'm an instructor. But my approach to sizing up students is much like my clinical style... I don't make judgements based upon one thing. If (1) the student looks way too casual during clinical, and (2) isn't answering call lights when not with their patient, and (3) isn't going up to their fellow classmates and saying "hey, I'm caught up with my patients, what can I do to help you?"... that would be one assessment. I would get some feedback from that student's clinical preceptor especially as it involves eagerness to be a part of the team. That would be another factor I'd consider. If when I express a coherent (hopefully factual) concern to the student, I don't get engagement (eye-contact, good questions, contrary opinion and input) that would be another assessment. If I suggested changes (which hopefully would be specific and not just vague rah-rah-step-it-up kind of stuff on the clinical unit)... and got butkis... that would also inform me. AND if, when I look at a student's written work (especially about their clinical experience... SBAR, Care-plans, etc.), and gave them ways to improve, and their next papers look like they phoned it in... well, now I have a pattern. At that point, you bet... I would pull you aside and ask you to examine how badly you want to be a nurse. If you are faultless in all those things, and if you're hearing this criticism from multiple sources, I'd work on my affect. Maybe you're doing all these things right, you're working hard and putting your shoulder to the wheel, but people just read you wrong. Rather than pretend to get hysterical and such, I'd suggest you work on making eye-contact, giving non-verbal cues that you're listening... that sort of thing. If you're getting this from people other than your instructor, then maybe you need to think about how you project yourself.

Yes. I was an RN then. I did not know any RN's who refused to take care of Gays, even those with what we were recognizing as Gay-related diseases such as Kaposi's sarcoma and pneumocistis. But we realized early on that it was body fluid related. So we became much, much, much more compulsive about gloving up. What concerned me the most was... I was lecturing on Tb and other public health issues. We had beaten tuberculosis back in the 50's and 60's. All the old Tb Sanitariums closed down. Antibiotics seemingly had relegated this disease to the dust-bin of history. As a result, governments in each state and around the world, stopped spending money protecting the public from Tb. When I was lecturing on this topic in the early 80's and doing reading on it, I realized we had disarmed at a time when we had a population of vulnerable patients expanding at a logarithmic rate. I could see (and predicted to my MD husband) that we were going to see tuberculosis roaring back as a public health epidemic and that it would become quickly antibiotic resistant. Sadly, I was right.

Our state fought back the "non-licensed assistive personnel" push years ago by lobbying our legislature really hard. As a result, certification of CNA's was put into the Nurse Practice Act and is regulated by our State Board of Nursing. But here is the dirty little secret. MA's in our state, have no certification, no practice limitations. They can do whatever the MD says they can do. (In theory, they could do brain surgery under supervision.) No one regulates them. And many of them are (forgive me) dumber than stumps. I've taught many MA's who are trying to become RN's and some are very bright. They learn quickly and many rise to the tops of their class. But they came in pretty ignorant and do no better than off-the-street beginning students. Does your state Nurses association have a lobbyist. I swear... you have got to fight this on the legislative level. I'm very disappointed in the ANA. Crickets.

Yes... almost ALL my students that work while going to school do so because they MUST. (Their job is where the health insurance is, or divorced spouse is not paying child support or whatever.) There is no good answer to whether "2nd semester" is easier than first. In our program the answer is ABSOLUTELY not. Fundies is where several out of every 37 student cadre crash and burn. 2nd semester is where many struggle and it's a ball-buster semester (in our program it's paired with Pharmacology AND Maternal-Child.) Again... I have not observed that CNA experience is a predictor of success. Neither is EMT. Some pass, some fail. Makes little difference.

Our school uses Ackley and Ladwig which... in its own way (this section for this... that section for that... flip here, turn there...) contains the 3 N's. And I know that Med-Surg I and II faculty (bless their hearts) do their best to show students how to use it. But I'm serious as a heart attack... when these students get to Med-Surg III they are clueless. And it cuts across GPA. The good students are as mystified as the weak ones. PS: I think I will also hang around the student pages more also. I just cannot understand why this is so hard.

Nursing school (doesn't matter ADN or BSN) is harder than you can possibly imagine. Not impossible. Just unbelievably demanding. My recommendation is that you clear the decks, make sure your car is in good working order and reliable, you have child-care all settled, and (if I may be so bold) don't get pregnant until your well within 9 months of graduation. Maximize your support systems, get your flu shot, don't get sick. Dump the demanding boy or girl friend. Only hang with people who are encouraging. Do everything you can to allow yourself at least 40 hours/week for class and study. Going to nursing school is a full time job. The CNA job really does not help you with the kind of cognitive leaps and bounds you're about to make. In fact, it can be an impediment. Professional nursing is orders of magnitude different than CNA duties. (Note... I didn't say more honorable or better or of more intrinsic value... I said professional nursing is different.) I cannot tell you the number of students I have urged (begged) to cut back or quit work. Many of them don't have the luxury. And many of those have had to repeat courses.

Yep. Read an analysis today that said that some small % of people who have signed up for insurance post ACA were genuinely unable to get insurance previously. It made the case that by expanding Medicaid and subsidizing the heretofore uninsurable, we could have covered them without the odious mandate that has thrown a monkey wrench into our entire health care system. It wasn't ever about the uninsured. It was always about the mandate.

I tell my students that PROFESSIONAL nursing is what goes on between the ears. And I put a lot of emphasis on teaching students how to reason about patient care. Here are my questions for you... 1) How much of nursing school should be spent teaching you skills and how much of your education should be devoted to clinical reasoning? (%-wise.) 2) Can you think of anything in your career as a student that has posed an obstacle to learning clinical reasoning? 3) Tell me one thing that really helped you "get" clinical reasoning.

I get that we need(ed) a standardized, agreed upon language for research and publishing and it's handy to have all of it (diagnoses, outcomes and actions) codified in EMR for the purposes of our own retrospective data collections. However, these (the 3N's) belong to NANDA-I. (To be honest... I don't know how anyone "owns" words, but there it is.) So, we may "think" them, we just can't publish and/or use them w/out permission. (I cannot publish a catalogue of the 3N's, for example.) So... when we try to teach students clinical reasoning, why do we constrict and restrict them to using the 3N's? 1) They won't remember it. 2) They can't take it with them 3) These tedious lists and labels are not part of the lingua franca of bedside nursing. Yet we put students through the wringer in classes and assignments forcing them to use this language to express their thoughts about patient care.

I have done 15 years of bench science (yep... whole deal, microscopes, tissue cultures, radioligand binding, measuring calcium transients with fluorescence, grant writing and publishing, blah-dee-blah) and I have a couple of advanced degrees. I guess I have as much science "cred" as anyone on this thread. And I know the evolution theory from both the molecular biological to the across-the-species-macro-evolution sides of it. And I'm an RN. And I'm an orthodox Christian. And I'm convinced a sovereign God created all there is. ON THE OTHER HAND... to my fellow Christians, I would suggest that the MOST important thing about the book of Genesis is "Who" and "why"... not "how" and "when". THE MOST IMPORTANT part of Genesis is that it begins the story of redemption. AND also to my fellow Christians, if you know your catechisms and confessions... you believe as I do that it's the Holy Spirit that brings people to belief... not our logic and eloquence (as if I had any... NOT!)

Not so much, bankruptcy due to medical bills is the number one cause of bankruptcy in the US. If everyone's insurance was working that well then few if any of these bankruptcies should have occurred to people with health insurance. In reality, about THREE QUARTERS of those bankruptcies occurred with who had health insurance. Part of what the ACA did was to make many more people responsible for their own health risks, which wasn't working without placing some minimum requirements on what could be called "insurance". Let's talk about that. I suppose I could in fact go bankrupt if an extended severe, devastating illness happens. (Which is one reason we homesteaded our house.) What you have now under O'care is people realizing they are priced out of insurance all together. This system requires the younger, healthier people (you know, the ones who are waiting tables after getting a Master's degree in something and are carrying $100K of non-dischargeable debt, who will never be able to qualify for a mortgage and are living with their parents... those young invincibles) to sign up for the program. What they are finding out is that they flat out don't have the money. Check it out... just a homely illustration... none of these under-employed 30 somethings are running out to buy a new car. They don't have $300/month for a payment. So, really... how many of them are going to volunteer to pay $480-$650/month for a product they don't want and will likely not use. So... yes, if I'm sick enough for long enough... I might go broke even though I'm insured. But O'care wipes millions of people out when they try to pay their first premiums. Which is a better system?

This is not a free market.

I think you are exactly the sort of family this program was supposed to help... and I'm gratified that it has helped you. According to CBS (as of several days ago) 2 million American families have been notified that they have lost their insurance, that the alternative plans are (in many cases) astronomically higher per month and have crazy high deductibles (5 figures.) BTW Not-a-Hat... please check your deductible. I hope it doesn't give you sticker shock. I would like to think someone is genuinely helped by this program. But does it seem rational that up to 90,000,000 Americans (Fobes' estimate for the number next year when the employer mandate goes into effect) will lose policies that have worked somewhat well to absolutely perfectly for them for many years... so that a small minority of people are assisted? And when Not-A-Hat's family gets on its feet and begins to live better... they will be in the same boat we all are. No. Just no. It was not about health insurance, it was about power.

The excuse de jour from the administration is that no one had to leave the health plans that they liked. But, you see... people are just being "transitioned" from "inferior" policies that did not quite meet ACA minimum standards. Oh, and if you are fortunate enough to be poor, you get a subsidy. But the subsidy (shhhhh this is a deep double dark secret) is TAXABLE INCOME!!!! Don't you just love it! Vis. the byzantine excuses and clarifications given above... our dealings with the insurance companies were sometimes frustrating. BUT... we had choices of multiple sources of insurance offerings from mini-med to cadillac plans. Now... not so much. I'm 64 years old and NOW I will get maternity coverage... and drug rehab insurance... which I've just pined for for years!!!! (tongue firmly in cheek.) Oh, THANK you President Obama. I'm SAVED from my terrible insurance. Let's go and lynch those awful, evil, arsonist, terrorist, anarchist Republicans who have been trying to keep us from having this blessing.

Um... where are all those valiant defenders of ObamaCare that were here a year ago? Totally flaming anyone who dared to have any doubts about how Democrat promises square with reality. Debacle. Train wreck. Disaster. Total fail. Incomprehensible. Illogical. Impossible. Unrealistic. Just some of the adjectives applied to the roll out by radical Tea Party news outlets like the Washington Post and the New York Times, CBS and NBC.

"My partner doesn't want to talk about dying, especially about my dying, so it gave me a chance to explore ideas with other people. I found comfort in that." And therein lies the tragedy. I feel great sadness and compassion for the individual. The cafe served a good purpose for him/her and one hopes this person found a sympathetic ear. But a culture that sees death cafes as something to celebrate... what have we become?