lwandel

Hi tseeton!! UWORLD? No, I don't think i've even heard of it! I'll look into that! Thank you! Prayers, best wishes and positive thoughts heading your way as you prepare for Monday! As steven would say, go Kill the NCLEX! Slit it's throat and drag it thru the mud! Face down! We've GOT THIS!!

I've been using the NCLEX RN Mastery app as well- but only when I'm at a stoplight or waiting in line and have a minute. After reading this, I think I'll use it more between now and Tuesday! CONGRATULATIONS on your success maybaycao!! Hopefully I'll be posting something similar here on Thursday!

I'm scheduled to take the NCLEX on 1/26/16 (in 3.5 days) and i'm REALLY nervous. I took the Hurst live review and I"m working my way thru the Q-reviews. For those of you that did Hurst and took the NCLEX, how did the q-review questions compare to the actual NCLEX? I just want to get an idea of how well i'm preparing...should I keep going with the q-reviews and hurst video or should I move onto a different prep method? Thanks so much for your feedback!

Yesterday was my medication administration day. I hep-locked a lumen on a double lumen PICC line. I want to make sure I'm documenting it correctly in my narrative notes. Stopped PRN 0.9% NS infusion into red lumen of PICC line. Used aseptic technique to disconnect IV tubing from red lumen port, capped IV tubing connector, and flushed line with prescribed 300 Units/3 mL Heparin Lock Flush while maintaining asepsis under supervision of instructor. I know the technical definition of "aseptic technique" is to use sterile gloves...but we used clean gloves. We made sure to quickly make the transition from disconnecting the IV tubing to connecting the heparin flush syringe and capping the IV tubing connector...is it considered "aseptic"? If not, how should I word that?

You're correct Isis, that's why I was struggling with using pain as a ndx. She only c/o pain with movement, otherwise she denied pain or her levels were 1-2/10. I am still working on this particular care plan, but the dxs I think I'm using are: 1. Imbalanced Nurtrition: less than body requirements r/t gastritis AEB abdominal pain, aversion to eating, low BMI, and poor muscle tone. 2. Constipation r/t decreased motility of GI tract and insufficient physical activity AEB straining with defecation, inability to pass stool, abdominal tenderness, anorexia, generalized fatigue and hard, formed stool. 3. Adult failure to thrive r/t fatigue AEB anorexia, unintentional weight loss of 15% in less than 6 months, evidence of fatigue, physical decline, and dehydration. How do these sound to you? I would love another opinion! Thanks, ~leslie

I certainly will let them know who made them. Thank you! And, just to give you and GrnTea a pat on the back, my instructor pulled me aside and asked me how I finally had my "AH-HA!" moment. I told her about you guys and this site and she had me share it with the rest of out clinical group during our post-conference time...I had already told them about it though. lol

She was prescribed morphine sulfate, tramodol and hydrocodone PRN, but was declining pain meds while I was there. Still trying to find the 3rd nsg dx.... Adult failure to thrive won't work because the only r/t factor is depression. and without an actual medical dx or history of depression, my instructor won't accept it. Can I use Risk for Electrolyte Imbalance if her labs already show that she has an electrolyte imbalance? Looking at Deficient Fluid Volume, that won't work because her vitals were all within an acceptable range and her Hct levels were low. I'll keep looking.....

These are great!!!!! I'm going to share them with my classmates as well. I know we're all struggling with these care plans.

Is it right to address two different causes of the same issue? I remember my instructor throwing out a dx of Impaired Skin Integrity with risk for further breakdown r/t physical immobility, inadequate nutrition, and bipap dependency (I was worried about the bipap machine causing the skin on her face to breakdown, in addition to the stage 4 sacral pressure ulcer and and the non-blanchable patches of skin on her heels). She said that I was addressing 2 different causes of the same issue and they needed to be different nsg dxs. I don't want to do the same thing with the constipation being r/t two different causes... What do you think? Never mind :) you just addressed it!

How about: Constipation r/t decreased motility of GI tract and insufficient physical activity AEB straining with defecation, inability to pass stool, abdominal tenderness, anorexia, generalized fatigue, and hard, formed stool. Is it right to address two different causes of the same issue? I remember my instructor throwing out a dx of Impaired Skin Integrity with risk for further breakdown r/t physical immobility, inadequate nutrition, and bipap dependency (I was worried about the bipap machine causing the skin on her face to breakdown, in addition to the stage 4 sacral pressure ulcer and and the non-blanchable patches of skin on her heels). She said that I was addressing 2 different causes of the same issue and they needed to be different nsg dxs. I really just need to print your "walkthough" and tape it on the wall by my computer so I can stop bothering you ladies. Lol thanks, Leslie

3 weeks prior to admission to the hospital, she had stimulators placed in her back (think tiny, sub-dermal TENS units). While I was working with her during my clinical, she denied pain, or said that her pain was 2-3 out of 10, except when she was repositioning her self into a laying or sitting position, then she would grimace and stop/slow down. But she would still deny pain. She denied pain medication also. Stated "it makes me sleepy and I don't like to just sleep all day. I'm not in any pain anyway". When I ascultated her abdomen, I did hear bowel sounds. They were slow, but rhythmic. When I pressed on the 4 quadrants of her abdomen, it did feel a little tight but, again, she denied pain. She only mentioned a little tenderness in her right upper quadrant. The day that I was with her was the day they took her back for an EDG and diagnosed her with gastritis and the hiatal hernia. The reason I'm not addressing pain in this is because she denied pain or, when she said there was pain, it was very minimal...except for the pain in her back when repositioning. Perhaps I could go with impaired comfort instead. I'll look up that NANDA in a bit and see if her assessments are a good fit. As for this diagnosis: Imbalanced Nutrition: less than body requirements r/t gastritis AEB abdominal pain, aversion to eating, low BMI, and poor muscle tone. It sounds a lot better to me, but I want to make sure. Thank you Esme12!! Leslie

ChipNurse, do you think I need to tweak my nursing diagnosis at all before I turn them in for my care plan? Thanks, Leslie

Thank you ChipNurse! Those are great ones too! Esme12 and GrnTea...do you wonderful ladies have any critiques for me too?

My pt is a 90 female pt that was admitted from home, where she lived alone, with a dx of: after care post surgery and severe malnutrition. Here are my findings so far: [TABLE] [TR] [TD]Cues/Data/Assessment Findings [/TD] [/TR] [TR] [TD]Under weight Ht: 63" Wt: 102 lbs [/TD] [/TR] [TR] [TD]fatigue [/TD] [/TR] [TR] [TD]Facial grimacing [/TD] [/TR] [TR] [TD]Muscle weakness [/TD] [/TR] [TR] [TD]Right side of abdomen tight and swollen upon palpation [/TD] [/TR] [TR] [TD]History of colon surgery: Portion of colon removed. [/TD] [/TR] [TR] [TD]C/o shoulder pain with activity [/TD] [/TR] [TR] [TD]C/o back pain with repositioning or activity [/TD] [/TR] [TR] [TD]Recent History of back surgery: Stimulators placed. [/TD] [/TR] [TR] [TD]Stated "my right side and belly feel tight and tender". [/TD] [/TR] [TR] [TD]Stated "I have a stool that won't come out. I need a laxative". [/TD] [/TR] [TR] [TD]Stated "I haven't had much of an appetite for weeks now". [/TD] [/TR] [TR] [TD]Stated "Before the surgery I weighed about 125 lbs. But I just haven't been hungry lately, so I lost a lot of weight". [/TD] [/TR] [TR] [TD]History of falls [/TD] [/TR] [TR] [TD]Age: 90 years old [/TD] [/TR] [TR] [TD]Opioids prescribed: morphine [/TD] [/TR] [TR] [TD][TABLE] [TR] [TD]Prealbumin 12.9 mg/dL Low (20-30) [/TD] [/TR] [TR] [TD]Sodium 124 mmol/L Low (136-143) [/TD] [/TR] [TR] [TD]Chloride 91 mmol/L Low (101-111) [/TD] [/TR] [TR] [TD]BUN 28 mg/dL High (7-20) [/TD] [/TR] [TR] [TD]Phosphorous 4.8 mg/dL High (2.4-4.4) [/TD] [/TR] [TR] [TD]Albumin 3.3 mg/dL [/TD] [/TR] [TR] [TD]Patient lives alone[/TD] [/TR] [TR] [TD]2+ edema present in both knees[/TD] [/TR] [TR] [TD][TABLE] [TR] [TD]Unequal pupils. Right pupil oval shaped and non responsive to light. Left pupil round and responsive to light [/TD] [/TR] [TR] [TD]Diminished hearing in right ear. Whisper test performed, patient unable to detect sound or repeat back what was whispered to her. [/TD] [/TR] [TR] [TD]Stated "I don't have a sense of smell. I can't smell anything anymore". [/TD] [/TR] [TR] [TD]gastritis[/TD] [/TR] [TR] [TD]hiatal hernia [/TD] [/TR] [TR] [TD]Stated "I just can't seem to get all of the stool out" [/TD] [/TR] [TR] [TD]Straining on defecation[/TD] [/TR] [TR] [TD]Stated "since I had most of my colon removed a few years ago, I have to use a laxative daily". [/TD] [/TR] [TR] [TD]Patient Activity: repositioning, simple assist to bedside commode, minimal activity.[/TD] [/TR] [TR] [TD]Anemia Hgb 12.0 g/dL, Hct 34.9%, RBC 4.5 mL/uL [/TD] [/TR] [TR] [TD][/TD] [/TR] [/TABLE] [/TD] [/TR] [/TABLE] [/TD] [/TR] [/TABLE] I have to present my instructor with 3 nsg dx's. She's very weak and underweight, so want to address that. Her constipation seemed to bother her a great deal. From the data above, these are some of the possible nursing dx's I can see: 1. Imbalanced nutrition: less than body requirements r/t protein and vitamin requirements for surgical wound healing and decreased desire to eat. (Should I put a "secondary to" here? If so, would it just be anorexia? Or should I go so far as to say "secondary to pain and fatigue" even though she was unable to relate her lack of appetite to anything specific when asked?) 2. Constipation r/t effects of immobility on peristalsis. or is there a way to relate it to the removal of a large portion of her colon, daily use of laxatives, and immobility? 3. Activity Intolerance r/t compromised oxygen transport system secondary to anemia. or I could go with a more psychosocial dx, but these are the ones that seemed pretty relevant. Are there any other ones that I missed that I should address before these? Or can I improve on the dx's I listed? Thank you, Leslie

Her O2 sat was 95% while resting. I was unable to get Resp. Ther. to come check it when she was going to the bathroom. Her c/o SOB was after ambulating to and from the bathroom. Once she got back in bed, she would say "phew, i can hardly breath", or "I need to catch my breath". Once she even had to use her inhaler. But i have no objective data to support impaired gas exchange, which is why i'm not going to use that dx right now. Since pain is the main priority, I want to go with that, but I'm not sure which nsg dx would best fit her needs. Should I just go with Acute Pain r/t osteomyelitis?

Hi May, there was no complaint of chest pain, only dyspnea with exertion. Her pain stems from her low back and osteomyelitis. She does have risk factors for heart disease, but my instructor seem to want us to focus on psychosocial and "at risk for _____ r/t medication" at this point in our clinicals. But, since i also have an exam on tuesday, this care plan may not meet all of her standards. I think the pain issue is more relevant than the risk for electrolyte imbalance. so I will probably go with that one. I do appreciate your comments :) Thanks, Leslie

Or, instead of focusing on pain, since my instructor wanted us to use an "at risk for..." r/t medication given, I guess I could use Risk For Electrolyte Imbalance r/t diuretic therapy, or would I need to get more specific with Risk For Hypokalemia r/t loop-diuretic therapy? Ugh. Stuck on this one.

I'm stuck on my 3rd diagnosis. I want to focus on her pain, because she consistently rated her pain as 8-9 out of 10 throughout my shift. Even after meds were given. It would drop down briefly to 7 at peak time, but would jump right back up to 9 out of 10. She was receiving pain medication every 1.5 hours to keep peak times in place. She was receiving morphine, hydrocodone, dilauded and tramadol. My pt. complained of both chronic back pain and acute pain in her foot r/t osteomyelitis. Since I'm dealing with both Chronic and Acute pain, should I go with a dx like Impaired Comfort? Impaired Comfort r/t Osteomyelitis?

Thank you Esme! I'm glad you liked it. My instructor has us list our Cues/Assessments on a different form, and cluster the cues/assessments in a group with each dx. It's strange, but that's how she likes it. Which is why I don't list the AEB's with the nsg dx...they're on a different form.

I am working on a second dx. I'm having trouble with this one. Here are my assessments so far related to this direction: Data: Obese- Ht. 63", Wt. 347.8 lb., 60 years of age sedentary activity patterns, patient stated "I know I need to lose weight", stated "I don't over eat. I control my diet well and I drink a lot of water", observed pt. requesting family to bring outside food observed pt. consuming outside food brought by family, patient requested additional food from Nutrition dept. directly after consuming breakfast. I don't know if this should go in the direction of Imbalanced Nutrition: More than body requirements, or Ineffective Health Maintenance...or is there a more psychosocial diagnosis that would help with this one? This is what I've come up with so far for this pt. Nsg Dx: Imbalanced Nutrition: More than body requirements r/t excessive caloric intake in relation to metabolic need. Goals: By discharge, patient will commit to a weight-loss program AEB 1. Client will state "I have committed to a weight loss program". 2. Client will demonstrate weight loss of 1-2 lbs per week. Interventions/Rationales 1. Intervention: Advise client to complete 1 week food intake and exercise journal that records: food intake, type of exercise, amount of exercise, location of meals, time of meals, and emotions around meal time, snacks, people with whom patient eats. Rationale: Overweight individual often report that their intake is less than it actually is. 2. Intervention: "Multiply female weight by 11 to determine caloric intake/day needed to maintain current weight. Teach patient that to lose 2 lbs./week, she must cut 7000 calories from weekly intake or increase exercise caloric expenditure". Rationale: "Intake must be reduced by 500 calories/day less than requirement to obtain 1 lb/week weight loss". 3. Intervention: "Collaborate with Physical Therapy department to assist client with identifying a realistic exercise program" (Cupernito, 2008, p. 318). Rationale: "Simplifying exercise regimens and tailoring them to individual lifestyles encourages adherence to exercise plan" (Ackley & Ladwig, 2011, p. 427). Critiques requested and welcome :) Thank you! lwandel

Hahah! I already posted my next one under 60 yo female with Osteomyelitis of R great toe :)

Please let me know how I can improve this dx and the related goals, interventions and rationales. I'm thinking I could go with either: Fatigue r/t inadequate tissue oxygenation secondary to anemia or Activity Intolerance r/t compromised oxygen transport secondary to anemia and asthma or Activity Intolerance r/t inactivity secondary to secondary to sedentary lifestyle and discomfort with ambulation I know that goals for fatigue focus on helping the pt adapt to the fatigue, and that activity intolerance goals focus on increasing tolerance to activity. I feel that, for this pt., I would like to focus the goals toward increasing activity. So, here's what I'm thinking of going with: Nsg Dx: Activity Intolerance r/t inactivity secondary to pain, dyspnea and sedentary lifestyle. Goals: By discharge, patient will not experience fatigue AEB 1. Patient will be able to perform ADL's without c/o dyspnea. 2. Patient will be able to ambulate length of hall without complaint of fatigue. 3. Patient will maintain normal blood pressure 3 minutes after activity. 4. Patient will rate pain less than or equal to 5 out of 10 on a scale of 1-10 during ambulation. Interventions / Rationales 1. Intervention: "Monitor and record the client's ability to tolerate activity: note pulse rate, blood pressure, O2 saturation, dyspnea, use of accessory muscles, and skin color before, during and after the activity" (Ackley & Ladwig, 2011, p. 120). Rationale:"Response to activity can be evaluated by comparing pre-activity BP, Pulse, Respiration and O2 saturation with post-activity results. These are compared with recovery time" (Carpenito, 2008, p. 63). 2. Intervention: "Treat pain before activity and ensure that the client is not heavily sedated" (Ackley & Ladwig, 2011, p. 121). Rationale: "Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement" (Ackley & Ladwig, 2011, p. 121). 3.Intervention: Have patient perform active ROM at least twice a day. Rationale: "Minimize the deconditioning effects of prolonged bed rest and imposed immobility". 4. Intervention: "Plan a purpose for each activity, such as walking to the window to see the view, or walking to the kitchen to get some ice water". Rationale: Strategies that are individualized can increase motivation. Please let me know how i can improve on this one. I'm going to work on the other 2 nsg dxs I need for this care plan. Thanks, lwandel

Esme12 and GrnTea...THANK YOU!!!!!! I got a 92 on this care plan! Thank you so very much! And my instructor asked that I pass on her thanks as well :) She said this was by far my best care plan and, because there were no big issues to mark off, the only points I had taken were for small things. Thank you again!!!!! You two ladies are wonderful!

Hello all :) I am working on another care plan that is due Monday morning. My pt is a 60 year old female with an admitting dx of Acute Osteomyelitis in great toe of R foot. I need 3 nsg dx- thinking of Imbalanced Nurtrition: more than, Acute pain r/t injury and fatiggue r/t anemia. Allergies: Penicillin, ibuprofen, vancomycin, promethazine, ciprofloxacen Relevant Health History: History of morbid obesity (63", 347.8lb) diabetes mellitus type2 Asthma History of GAVE Syndrome (gastric antral vascular ectasia, aka watermelon stomach; acute or chronic gastrointestinal blood loss). Hypertension Chronic LBP Irritable Bowel Syndrome previous history of depression LABS/TESTS: WBC- 6 k/u RBC 2.95 ml/ul hemoglobin- 8.7 g/dl hematocrit- 26.3% Segmented neutrophils 68% Lymphocytes- 14% Eosinophils 7% Sodium 135 mmol/l Chloride 99mmol/l Glucose 157 mg/dL BUN- 24 mg/dl Albumin- 3.2 g/dl Uric Acid- 10.2 Magnesium - 1.6mg/dl ASSESSMENTS: c/o SOB with exertion Stated "Pain 8/10" after peak time for pain medication administered. Consumed outside food that family brought for her. Requested more food from Nutrition dept. after breakfast was served and consumed. T- 97.9 Bp 120/64 RR -14 regular P-74, 2+, regular Capillary refil Diet: Consistent Carbohydrate- 15/24 hr period

Oh yeah, this poor guy...I definitely don't envy him. Ok, so... Nsg Dx: Stress Overload r/t Inadequate Resources and multiple coexisting stressors. Goal: Patient will verbalize reduction in stress levels through use of relaxation techniques and other strategies AEB Will state implementation of at least one alternative method of reducing stress Will rate stress level at less than or equal to 4 on a scale of 1-10. Interventions: Explore possible therapeutic approaches such as cognitive behavior therapy, biofeedback, neurofeedback, pharmacologic agents, relaxation techniques, breathing techniques, visual imagery, and soothing rituals. . Rationale: Neurofeedback promotes optimum functioning of the central nervous system, induces relaxation, and supports resilience" (Ackley & Ladwig, 2011, p. 806). Listen actively to descriptions of stressors and the stress response. Rationale: Developing nurse-client partnerships is the best way to obtain valid and reliable information related to stress overload" (Ackley & Ladwig, 2011, p. 806). Categorize stressors as modifiable or nonmodifiable. Help patient modify or mitigate stressors identified as modifiable. Rationale: Removing or minimizing some stressors, changing responses to stressors, and modifying the long-term effects of stress are all actions that can assist those with illness and stress" (Ackley & Ladwig, 2011, p. 805). Assist the client to mobilize social supports for dealing with recent stressors. Rationale: Emotional and social support moderates the impact of recent but not chronic life stress on physical symptom reporting" (Ackley & Ladwig, 2011, p. 806). How does this one sound?