olaureno

I recently began a RN position in a medically assisted detox center. Many of the opioid withdrawal symptoms are manageable with the PRNs available. However one of the symptoms I can't really pin down with a treatment are the abdominal cramps. Is it the beginning of withdrawal diarrhea? I'm not really sure whether I should go with stool softeners, ranitidine, tums, imodium, etc. Is there anything I can do besides meds for my patients as well? I'm big on non-pharm interventions in combination with meds. My patients think I'm a little bonkers when I give them chamomile tea with their anti-anxiety meds :)

I'm working on a group project and I think we're stuck. The hypothetical patient has advanced dementia such that she cannot recognize family members and has been hospitalized numerous times. She has no advanced directive and is incapable of making medical decisions. She is in skilled nursing following a hospitalization for aspiration pneumonia. She had a j-tube placed, approved by her husband (and caregiver) who was under the impression that it was a temporary measure and not meant to be life-long. She is becoming increasingly combative- part of which is due to her desire to eat and being NPO. Her quality of life has become quite poor and she is unable to perform ADL's independently. The distraught husband has expressed interest in assisted suicide. In Oregon we do have Death with Dignity, however she is not elligible due to her advanced dementia. My own research has indicated that artificial nutrition and hydration for patients with advanced dementia causes more harm than good.(https://sites.ualberta.ca/~loewen/Medicine/GIM%20Residents%20Core%20Reading/ANOREXIA%20AND%20WEIGHT%20LOSS/Pegs%20dementia%20editorial.pdf) It is my understanding that the nurse cannot stop tube feeding without the patient requesting it- something that cannot happen. I feel that continuing tube feeding is causing harm to the patient, but who can make the decision to stop feeding? What does the law say? I have been at this for hours and I have no idea how to proceed. Any hospice nurses out there to save me??

I just wanted some feedback on my priority issues- my identified nursing diagnoses. These are listed at the bottom of the case study in italics. Do they seem appropriate? Do they seem tailored to this particular placement? We are supposed to put them in order of immediate importance. This is what I'm having the most trouble with. What order would you put them in? What is your thought process behind it so I can compare it to mine?

Family Name: ***** Family Members & Profiles ********, 13 years old, from Texas, Type I Diabetic Introduction/ Background: An anxious-looking ******, just arrived without report or notification on a gurney from the ED Situation: Chart data: History reveals that ****** is a 13-year-old student attending middle school in Texas who was diagnosed with type 1 diabetes a year ago. Last weekend, ***** and several of his friends traveled with his family to a beautiful beach in Mexico for a weekend of sun, swimming, and fun. On the last day of the weekend, ***** stubbed his right toe on a nearby rock during a volleyball game that resulted in a small, open cut. At the time, ***** didn't pay much attention to it; he kept on playing. After the game, he put his sandals on and headed back to the motel room to pack for the drive home. When getting out of the car, ***** noticed his right toe was swollen and reddened. The first thing he did when returning home was to rinse his toe with cool water before going to bed. ***** awoke in the early hours of the next morning with vomiting, fever, and diarrhea. His flu-like symptoms and continued anorexia lasted about a week. ***** stopped taking his usual insulin regimen two days prior to admission to the ED because of his inability to eat. *****was admitted to the ED via ambulance and presented with the typical signs and symptoms of DKA. ***** experienced a drop in his BP to 88/50 mm Hg and was stabilized in the ED with an infusion of 0.9% NaCl, the same crystalloid solution that was infusing as he arrived on the medical unit. Initial lab results from the ED include: blood glucose (540 mg/dL) serum sodium (129 mEq/L) serum potassium (5.0 mEq/L) serum chloride (94 mEq/L) BUN (70) serum osmolality (319 Osm/L) pH (7.23) partial pressure of carbon dioxide (pCO2) (22) HCO3 (8) New orders included the establishment of a regular insulin intravenous (IV) drip along with serum glucose, electrolyte labs, and other blood studies per protocol; oxygen via nasal cannula; activity restrictions; and other ongoing monitoring orders necessary for managing quick changes in health status secondary to treatment modalities. Unfolding data: Client Assessment Data as documented by Nurse on admission: VS: T99.0, P120, R28, 105/72 Assessment: Neuro: Oriented to self, but confused to time and place. Unsteady gait. CV: Regular rate and rhythm; diminished peripheral pulses; positive skin tenting, capillary refill >3 seconds. Respiratory: Lung sounds clear but dyspnea with increased rate. Fruity breath. GI: Nausea and vomiting with emesis of 50 mL of green bile fluid during admission process. GU: Subjective: I peed a cup full this morning.” Integumentary: Skin flushed, dry and warm. R great toe is swollen and inflamed with an open laceration midline above the nail of great toe-draining slight amount of yellow fluid. Musculoskeletal: Generalized weakness. Priority issues: - Alterned fluid and electrolyte balance r/t vomiting, diarrhea and osmotic diuresis - Altered nutrition r/t impaired utilization of nutrients - Dyspnea r/t respiratory compensation for metabolic alkalosis - Anxiety r/t dyspnea, disorientation, fear of bodily injury, fear of medical procedures, fear of separation from family/friends, fear of violation of body autonomy - Alteration in comfort r/t nausa, vomiting, painful toe, shortness of breath, fatigue - Risk for fall/injury to self r/t acute disorientation, unsteady gait, generalized weakness - Risk for sepsis? Something to do with the infected toe

the smell thing gets me. i find it really distracting and disrespectful to the patient when I'm working with someone who smells like a cloud of cigarette smoke. healthcare workers should present themselves as professionals, and part of that is not smelling strongly of anything good or bad.

Thank you both for your input. Below is a copy of my next case study and below that are the dx's I have identified. I would love to get your feedback especially about tailoring my dx's to the pt. Thank you!!!! Family Name: Hogan Family Members & Profiles Bobby Hogan, 13 years old, from Texas, Type I Diabetic Introduction/ Background: An anxious-looking Bob Hogan, just arrived without report or notification on a gurney from the ED Situation: Chart data: History reveals that Bobby Hogan is a 13-year-old student attending middle school in Texas who was diagnosed with type 1 diabetes a year ago. Last weekend, Bobby and several of his friends traveled with his family to a beautiful beach in Mexico for a weekend of sun, swimming, and fun. On the last day of the weekend, Bobby stubbed his right toe on a nearby rock during a volleyball game that resulted in a small, open cut. At the time, Bobby didn't pay much attention to it; he kept on playing. After the game, he put his sandals on and headed back to the motel room to pack for the drive home. When getting out of the car, Bobby noticed his right toe was swollen and reddened. The first thing he did when returning home was to rinse his toe with cool water before going to bed. Bobby awoke in the early hours of the next morning with vomiting, fever, and diarrhea. His flu-like symptoms and continued anorexia lasted about a week. Bobby stopped taking his usual insulin regimen two days prior to admission to the ED because of his inability to eat. Bobby was admitted to the ED via ambulance and presented with the typical signs and symptoms of DKA. Bobby experienced a drop in his BP to 88/50 mm Hg and was stabilized in the ED with an infusion of 0.9% NaCl, the same crystalloid solution that was infusing as he arrived on the medical unit. Initial lab results from the ED include: blood glucose (540 mg/dL) serum sodium (129 mEq/L) serum potassium (5.0 mEq/L) serum chloride (94 mEq/L) BUN (70) serum osmolality (319 Osm/L) pH (7.23) partial pressure of carbon dioxide (pCO2) (22) HCO3 (8) New orders included the establishment of a regular insulin intravenous (IV) drip along with serum glucose, electrolyte labs, and other blood studies per protocol; oxygen via nasal cannula; activity restrictions; and other ongoing monitoring orders necessary for managing quick changes in health status secondary to treatment modalities. Unfolding data: Client Assessment Data as documented by Nurse on admission: VS: T99.0, P120, R28, 105/72 Assessment: Neuro: Oriented to self, but confused to time and place. Unsteady gait. CV: Regular rate and rhythm; diminished peripheral pulses; positive skin tenting, capillary refill >3 seconds. Respiratory: Lung sounds clear but dyspnea with increased rate. Fruity breath. GI: Nausea and vomiting with emesis of 50 mL of green bile fluid during admission process. GU: Subjective: I peed a cup full this morning.” Integumentary: Skin flushed, dry and warm. R great toe is swollen and inflamed with an open laceration midline above the nail of great toe-draining slight amount of yellow fluid. Musculoskeletal: Generalized weakness. Priority issues: - Alterned fluid and electrolyte balance r/t vomiting, diarrhea and osmotic diuresis - Altered nutrition r/t impaired utilization of nutrients - Dyspnea r/t respiratory compensation for metabolic alkalosis - Anxiety r/t dyspnea, disorientation, fear of bodily injury, fear of medical procedures, fear of separation from family/friends, fear of violation of body autonomy - Alteration in comfort r/t nausa, vomiting, painful toe, shortness of breath, fatigue - Risk for fall/injury to self r/t acute disorientation, unsteady gait, generalized weakness - Risk for sepsis? Something to do with the infected toe

i guess i put the cart before the horse a bit on this one. i need to focus more on immediate issues than those that are yet to develop. perhaps its also an issue of not really understanding heparin therapy in an active clot. on paper i understand how it works and the possible side effects but in real life how often would you see excess bleeding? how bad is this bleeding usually? in this case i was not given any related lab values but are there other factors that could impact the risk for bleeding?

Hi, I recently completed a pretty straight forward case study about a woman admitted with a PE on a heparin drip. I thought I had a pretty solid list of nursing issues including impaired gas exchange, impaired hemodynamics, pain, anxiety, education needs, etc (all phrased and framed correctly of course) and I had risk for bleeding as my third priority issue. When I got my paper back, the instructor had written that risk for bleeding is not a priority issue. I would like to discuss this further with her but I would like to have some literature and rock solid argument to back me up. My school will not accept anything older than 2010 as evidence for argument. I normally only receive positive feedback on my case studies, so I am concerned that either year two is squirrelly or I'm missing something. Thanks!!

Hi there, I'm preparing for a simulation lab this week that may involve a patient developing sepsis. His orders indicate that he is due to have his CVC dc'd today. The area around the CVC site looks pink. Vitals and labs indicate the onset of sepsis and from what I've read it is best to have a CVC in place to administer treatment in such cases. Even though the CVC may have been the site of infection do we really want to remove it? I haven't been able to find anything that would shed light on the subject. Thanks!

Hi there, I am hoping someone can shed some light on a problem I am having with possibly overextending myself with my school, work and volunteer schedule. I am intending on applying to Oregon Health and Sciences University's accelerated bsn program a year from now. In 2010 I graduated with a BA in psychology from Reed college- a relatively tough school with a nerdy reputation :) with a 3.23 gpa. Not great I know, but about average for the school, and keeping in mind there have only been a handful of students that have graduated from reed with a 4.0. And to graduate you have to complete a year long research thesis, so I am hoping that will somewhat distinguish me from the rest of the applicants. Anyway, academically I am working on my prereques and have earned 3 solid A's in a 100 level chem class, A&P1 and micro. (I havent recalculated my gpa). I have ~3 years employment in mental health plus about a year of volunteering with survivors of sexual assault via a hotline and in a hospital setting. In october I became a CNA and have been working 3 days a week for about two months now- swing shift. Here's where the trouble comes in. I want to take A&P2 and nutrition next quarter and I also got a sought after volunteer position as a clinic assistant with a wonderful organization in the area that serves homeless youth. I will be able to learn a ton of really practical information and it is about 7 hours a week. I also need to study this term to take the math placement test to get into Math 111 for the term after next so that I can take a 200 level chem class, to further up my poor gpa. As I said I think I might be overextending myself and I dont want my ambition to work to my disadvantage. I need the job, but I don't know whether to back out of one of my classes for to forego the volunteer position. I guess I am asking if experience or gpa is more important. Any ideas? Thank you!!!

Hi there, I was just wondering if it's really worth it to take chemistry to get into a tough RN program even if it's not a prerequisite for the program. I was thinking about doing it to perhaps be a stronger applicant but I'm not sure how much edge it would give me vs the time it would take to get through all three classes. Would my time and effort be better spent elsewhere taking different classes, volunteer work, etc? Thanks for any thoughts on the subject!

yep learned my lesson for taking classes online. took an intro chem class and didnt do anything for the class for almost a month during the term. luckily the course was slow paced and I was able to do some heavy duty cramming in the end (and actually got an A). never again though. I think I would have learned the material better and probably faster if I had taken the traditional chem class. it was just last term and I dont think Ive retained a darn thing

I am interested in getting my ABSN and I would like to do trauma work, perhaps become a SANE nurse as well. I am very interested in the program at OHSU and think that with all the research and advanced programs there it would give me some great opportunities after granduation. My longterm boyfriend works for the park service seasonally and I would like the ability to travel with him (and travel in general) and would love to spend time as a traveling nurse, especially in rural areas (I love Alaska!). So here's my problem- I am going to do all my prereqs and do my best to ace them but as far as experience goes I dont know which direction to go. I have my BA in psychology and have worked as a direct care worker with individuals with mental illness for a number of years. I recently quit my job in supportive housing to live in the middle of nowhere to do native seed collection for the park service for the summer, you know, for a change of pace :) OHSU, unlike many other schools, does not look for work as a CNA for experience but is looking more for applicants with truely unique experiences. Id rather not work as a CNA as it seems primarily hospice and due to current events in my life its a little too close to home right now. I was thinking EMT as it is more trauma focused, but there are very few jobs in Portland as an EMT. Or... I could go totally opposite and keep going with unique jobs like working for the park service. Perhaps become a wilderness first responder and hope for some experience to present itself. A couple years ago I volunteered with the sexual assault resource center in portland for over a year where I had to accompany survivors to the ER and act as their advocate, working with police and the SANE nurse. I could do that agin while I am in Portland for my prereqs, though I would have to do a 40hr training all over again and commit to 24/month on top of school and whatever job I pursue. I really don't know which way to go and I am afraid I just wont decide and try to do them all at once somehow (yikes!). Any ideas? Thanks!!!!

From what I've heard A&P II is easier than I and while I think the course builds on itself, the fact that its usually divided into systems I think makes it easier if we've forgotten something from the previous unit. I'll be taking both I and II in the fall so it will be interesting to see how much I've forgotten from over a year ago and how much I should have retained to be on top of A&P II

Scientist- hmm I hadn't thought about language classes. I took a bit of spanish in college, but remember nothing. I'll look into that. The cost factor between schools is important too, something like $1000 difference for some classes. Mandy- I would be retaking A&P 1 because I was rocking the class until I let things slide a bit then some family stuff happened... basically I know I can earn an A and I want that reflected on my transcript. Plus OHSU has something like a 29% acceptance rate and I want to know that I am applying having put forth my best effort. My counselor agreed, but thought I was being a bit neurotic about potentially retaking developmental psych with a B+. :)