CTrain

This is really disappointing to read. I work in the ER and actually have a coworker who hid in the bathroom while HER patient coded. I honestly don't trust her with anyone at this point and have zero respect for her as an RN. It comes with the territory no matter what department you're in, you never know what can change, and hiding isn't a solution. I always take comfort in knowing the majority of my coworkers are right there in the **** with me when the ER gets crazy. Codes are not so scary when you know its a team effort. Clearly you aren't making any effort. Even if you aren't in the code because it may not be your "forte" and that's okay, at least go make rounds on other nurses patients to make sure they are okay while that nurse is busy helping a dying patient, holding down the fort is being a team player.

We have a 4:1 ratio for ER patients. If the patient is ICU, you are 2:1 unless the patient is unstable then its 1:1, or someone else gets the patient set up until the primary nurse can care for both. If it is a step down from ICU it is 3:1. I think the 5 and 6 ratios are unsafe in an ER setting unless they are "hallway" patients who are not critical. At times I'll have 10-15 "clinic" patients who need prescriptions and medications. However, if patients do not have admitting orders yet, but they will be an admit to ICU, we have to tell our charge so we are not over ratio and assignments can be rearranged.

So, is it possible that he has early emphysema that could also be interfering with O2 exchange. He does have home albuterol, and clubbing of the fingers which shows me something has been going on for a while. But by the same token he clearly has a lack of RBCs, iron, H&H which would cause a low O2 sat. I guess I'm looking at this like he has chronic infection, anemia, CHF, and now a respiratory problem that are all requiring an O2 demand beyond what he can supply, but I'm trying to decipher what is causing what or if they are completely separate. I feel like the lines between the conditions are becoming blurred even with a concept map. SOB and weakness are symptoms from anemia, CHF, and emphysema.

As far as I know, there was no mention of valve dysfunction, and no mention of right side having any issues. The pt. denied SOB with exertion but was on bedrest, so that may be why he denied it. I checked for edema around the sacrum and it was not present. He was very asymptomatic, and most of his s/s were blamed on the anemia which is always a possibility. Majority of his care was aimed at the anemia, yet his dx was CHF. I'm just confused as to why their care plan had decreased cardiac output when he wasn't showing any hard signs of decreased cardiac output like I'm used to with other patients.

My pt. is a 67 yo male (BMI 24) Chief complaint: SOB, weakness, syncope HX: HTN, hypotension, syncope, GI bleed - av malformation in stomach (2 negative guaiac as of my shift), GERD, ESBL in the urine x3 years, pneumonia, type 2 diabetes mellitus x 1 year, iron deficiency anemia, chronic pancreatitis, osteoporosis, osteoarthritis, and prostate cancer 2011. Alcohol, cigarette, amphetamine, methamphetamine, cocaine, and marijuana use x 50 years DX: CHF Assessment showed: Pt. calm, alert, oriented x 4 No SOB, inspiratory crackles to lower right lobe, clubbing of the fingers S1 S2 audible, no extra sounds heard, regular rhythm, radial pulses strong, Telemetry SR 110 Weakness in lower extremities, partial ROM, pedal pulses weak, pedal cap refill Pt. had no other significant findings LABS: [TABLE] [TR] [TD]WBC [/TD] [TD]4.8-10.7 x10^3/uL [/TD] [TD]6.8 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]RBC [/TD] [TD]4.47-5.60 x10^6/uL [/TD] [TD]4.00 [/TD] [TD]4.46 [/TD] [TD] [/TD] [/TR] [TR] [TD]Hemoglobin [/TD] [TD]14.7-16.6 g/dL [/TD] [TD]8.0 [/TD] [TD]9.7 [/TD] [TD] [/TD] [/TR] [TR] [TD]Hematocrit [/TD] [TD]40.0-48.2 % [/TD] [TD]27.5 [/TD] [TD]31.6 [/TD] [TD] [/TD] [/TR] [TR] [TD]MCV [/TD] [TD]80.0-96.0 fL [/TD] [TD]68.8 [/TD] [TD]70.9 [/TD] [TD] [/TD] [/TR] [TR] [TD]MCH [/TD] [TD]27.0-33.0 g/dL [/TD] [TD]20.0 [/TD] [TD]21.7 [/TD] [TD] [/TD] [/TR] [TR] [TD]MCHC [/TD] [TD]32-36 g/dL [/TD] [TD]29.1 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]RDW [/TD] [TD]11.5 – 14.7 fL [/TD] [TD]18.5 [/TD] [TD]18.5 [/TD] [TD] [/TD] [/TR] [TR] [TD]Platelets [/TD] [TD]130-400 x10^3/uL [/TD] [TD]257 [/TD] [TD]245 [/TD] [TD] [/TD] [/TR] [TR] [TD]Monocytes [/TD] [TD]4.0-11.0 % [/TD] [TD]6.0 [/TD] [TD]9.9 [/TD] [TD] [/TD] [/TR] [TR] [TD]Basophils [/TD] [TD]0.0-0.1 % [/TD] [TD]0.9 [/TD] [TD]0.4 [/TD] [TD] [/TD] [/TR] [TR] [TD]Lymphocytes [/TD] [TD]18.0-45.0 % [/TD] [TD]22.1 [/TD] [TD]26.2 [/TD] [TD] [/TD] [/TR] [TR] [TD]Eosinophils [/TD] [TD]0.0-6.0 % [/TD] [TD]6.2 [/TD] [TD]1.2 [/TD] [TD] [/TD] [/TR] [TR] [TD]Neutrophils [/TD] [TD]44.0-72.0 [/TD] [TD]64.7 [/TD] [TD]61.4 [/TD] [TD] [/TD] [/TR] [TR] [TD=colspan: 5]CMP [/TD] [/TR] [TR] [TD]Sodium [/TD] [TD]137-145 mmol/L [/TD] [TD]139 [/TD] [TD]140 [/TD] [TD] [/TD] [/TR] [TR] [TD]Potassium [/TD] [TD]3.5-5.3 mmol/L [/TD] [TD]3.8 [/TD] [TD]3.8 [/TD] [TD] [/TD] [/TR] [TR] [TD]Chloride [/TD] [TD]98-107 mmol/L [/TD] [TD]103 [/TD] [TD]105 [/TD] [TD] [/TD] [/TR] [TR] [TD]CO₂ [/TD] [TD]22-30 mmol/L [/TD] [TD]21 [/TD] [TD]23 [/TD] [TD] [/TD] [/TR] [TR] [TD]Glucose [/TD] [TD]70-110 mg/dL [/TD] [TD]113 [/TD] [TD]92 [/TD] [TD] [/TD] [/TR] [TR] [TD]BUN [/TD] [TD]9-20 mg/dL [/TD] [TD]18 [/TD] [TD]30 [/TD] [TD] [/TD] [/TR] [TR] [TD]Creatinine [/TD] [TD]0.7-1.3 mg/dL [/TD] [TD]1.12 [/TD] [TD]1.15 [/TD] [TD] [/TD] [/TR] [TR] [TD]Calcium [/TD] [TD]8.1-10.2 mg/dL [/TD] [TD]8.7 [/TD] [TD]8.1 [/TD] [TD] [/TD] [/TR] [TR] [TD]Protein [/TD] [TD]6.4-8.2 g/dL [/TD] [TD]8.6 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Albumin [/TD] [TD]3.5-5.5 g/dL [/TD] [TD]4.1 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Globulin [/TD] [TD]1.6-3.4 g/dL [/TD] [TD]4.5 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]A/G Ratio [/TD] [TD]1.1-2.2 [/TD] [TD]0.9 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Bilirubin [/TD] [TD]0.0-1.0 mg/dL [/TD] [TD]0.7 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]ALT [/TD] [TD]21-71 U/L [/TD] [TD]21 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]AST [/TD] [TD]17-59 U/L [/TD] [TD]30 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Calculated Ca [/TD] [TD]Mg/dL [/TD] [TD]8.6 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Iron [/TD] [TD]49-181 [/TD] [TD]13 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Iron Binding [/TD] [TD]250-450 [/TD] [TD]460 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]% Saturation [/TD] [TD]20-55% [/TD] [TD]3 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Magnesium [/TD] [TD]1.5-2.5 mEq/L [/TD] [TD]N/A [/TD] [TD]1.7 [/TD] [TD] [/TD] [/TR] [TR] [TD]Phosphorus [/TD] [TD]3.0-4.5 mg/dL [/TD] [TD]N/A [/TD] [TD]4.1 [/TD] [TD] [/TD] [/TR] [TR] [TD=colspan: 5]Urinalysis [/TD] [/TR] [TR] [TD]GFR [/TD] [TD]>90 [/TD] [TD]N/A [/TD] [TD]>60 [/TD] [TD] [/TD] [/TR] [TR] [TD]Color [/TD] [TD]Yellow-Amber [/TD] [TD]Yellow [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Appearance [/TD] [TD]Clear [/TD] [TD]Clear [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Specific Gravity [/TD] [TD]1.006-1.035 [/TD] [TD]1.010 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]PH [/TD] [TD]5.0-8.0 [/TD] [TD]5.5 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Leukocytes [/TD] [TD]Negative [/TD] [TD]2 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Nitrites [/TD] [TD]Negative [/TD] [TD]Pos [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Protein [/TD] [TD]Negative [/TD] [TD]Neg [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Glucose [/TD] [TD]Negative [/TD] [TD]Neg [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Ketones [/TD] [TD]Negative [/TD] [TD]Neg [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Bilirubin [/TD] [TD]Negative [/TD] [TD]Neg [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Blood [/TD] [TD]Negative [/TD] [TD]2+ [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Epithelial Cells [/TD] [TD]0-3 hfp [/TD] [TD]None [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]WBCs [/TD] [TD] [/TD] [TD]262.0 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]RBCs [/TD] [TD] [/TD] [TD]153.6 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Bacteria [/TD] [TD]Negative [/TD] [TD]Mod [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [TR] [TD]Casts [/TD] [TD]0-2.0/uL [/TD] [TD]2.28 [/TD] [TD]N/A [/TD] [TD] [/TD] [/TR] [/TABLE] [TABLE] [TR] [TD]CK [/TD] [TD]21-232 U/L [/TD] [TD] 46 [/TD] [TD]N/A [/TD] [/TR] [TR] [TD]NT – ProBNP [/TD] [TD]Pg/mL [/TD] [TD]2760 [/TD] [TD]N/A [/TD] [/TR] [TR] [TD]Troponin I [/TD] [TD]0.0-0.034 ng/mL [/TD] [TD]0.018 0.012 [/TD] [TD]N/A [/TD] [/TR] [/TABLE] [TABLE] [TR] [TD]Chest X-Ray [/TD] [TD]Mild pulmonary hyperinflation with mild diffuse airspace opacities. Positive for superimposed interstitial edema. [/TD] [/TR] [TR] [TD]CT of Head [/TD] [TD]Mild cerebral atrophy, widening of extra axial spaces. Mild atherosclerotic calcifications of distal internal carotid [/TD] [/TR] [TR] [TD=colspan: 2]Ultrasound [/TD] [/TR] [TR] [TD]2DEcho [/TD] [TD]R lower carotid – intimal thickening Minimal arthrosclerosis Ejection Fraction 65% [/TD] [/TR] [/TABLE] Home Meds [TABLE] [TR] [TD]Acetaminophen [/TD] [TD]500mg [/TD] [TD]PO [/TD] [TD]Q6HR PRN [/TD] [TD] For mild pain [/TD] [/TR] [TR] [TD]Albuterol Sulfate [/TD] [TD]90mcg [/TD] [TD]Inh [/TD] [TD] [/TD] [TD]For shortness of breath [/TD] [/TR] [TR] [TD]Ciclosporine [/TD] [TD]0.5% [/TD] [TD]Drop [/TD] [TD] [/TD] [TD]For dry eyes [/TD] [/TR] [TR] [TD]Escitalopram [/TD] [TD]10 mg [/TD] [TD]PO [/TD] [TD]QDAY [/TD] [TD]For depression [/TD] [/TR] [TR] [TD]Furosemide [/TD] [TD]20 mg [/TD] [TD]PO [/TD] [TD]QDAY [/TD] [TD]To decrease BP and fluid volume [/TD] [/TR] [TR] [TD]Lipase-Protease- Amylase [/TD] [TD]24,000u 76,000u 120,000u [/TD] [TD]PO [/TD] [TD]QDAY [/TD] [TD]To aid in digestion [/TD] [/TR] [TR] [TD]Pantoprazole [/TD] [TD]40mg [/TD] [TD]PO [/TD] [TD]QDAY [/TD] [TD]To decrease gastric acid secretion [/TD] [/TR] [TR] [TD]Saxagliptin [/TD] [TD]5mg [/TD] [TD]PO [/TD] [TD]QDAY [/TD] [TD]To decrease blood sugar [/TD] [/TR] [TR] [TD]Tramadol [/TD] [TD]50mg [/TD] [TD]PO [/TD] [TD]Q6HR PRN [/TD] [TD]Arthritis pain [/TD] [/TR] [/TABLE] Hospital Meds [TABLE] [TR] [TD]Aspirin EC [/TD] [TD]81 mg [/TD] [TD]PO [/TD] [TD]QDAYx30Days [/TD] [TD]Blood thinner [/TD] [/TR] [TR] [TD]Escitalopram [/TD] [TD]10 mg [/TD] [TD]PO [/TD] [TD]QDAYx30Days [/TD] [TD]Depression [/TD] [/TR] [TR] [TD]Ferrous Sulfate [/TD] [TD]324 mg [/TD] [TD]PO [/TD] [TD]QDAYx30Days [/TD] [TD]To increase iron [/TD] [/TR] [TR] [TD]Lipase/Protease/Amylase [/TD] [TD]24,000u 76,000u 120,000u [/TD] [TD]PO [/TD] [TD]TIDx30Days [/TD] [TD]Pt has chronic pancreatitis and has poor digestion of fats, proteins, and carbohydrates. [/TD] [/TR] [TR] [TD]Saxagliptin [/TD] [TD]5 mg [/TD] [TD]PO [/TD] [TD]QDAYx30Days [/TD] [TD]To decrease blood sugar [/TD] [/TR] [TR] [TD]Ceftriaxone [/TD] [TD]1g [/TD] [TD]IVBP [/TD] [TD]Q24HR [/TD] [TD]To treat e-coli infection in the bladder [/TD] [/TR] [TR] [TD]Insulin Regular [/TD] [TD]Scale [/TD] [TD]SQ [/TD] [TD]AC/QHS [/TD] [TD]To decrease blood sugar [/TD] [/TR] [TR] [TD=colspan: 5]PRN [/TD] [/TR] [TR] [TD]Dextrose 50%/NACL [/TD] [TD]25 g [/TD] [TD]IV [/TD] [TD]PRN [/TD] [TD]To raise blood sugar [/TD] [/TR] [/TABLE] I hope I provided enough information. He has been diagnosed with CHF. As I'm doing my care plan, I notice he only has a few signs and symptoms of CHF which I assume is because it is new onset. The hosptialist has designated that his syncope, sob, and weakness was caused due to iron-deficiency anemia, not the CHF. Thus far, all I'm seeing that remotely ties in with CHF are: NT-Bnp Risk factors: HTN (which was not present in the hospital BP was around 116/82) Smoking Diet high in fatty fried foods. The echo showed EF of 65% which my book deems as normal for his age. Most of his signs and symptoms present seem to be due to the anemia (he recieved 2 units PRBCs on my shift). Am I missing anything that might not be extremely obvious to me? What are they seening besides the NT-Bnp levels that I'm not?

I have to use a wellness diagnosis.

Pt. Info: 22 year old, G3P3, repeat c-section with intrathecal analgesia at 21:52 on 3-27 (I gave care on the 28th), dermabond to incision. GBS negative, Rubella immune. NKA. Pt. has been given phenergan and zofran for nausea. Pt. has venodines and foley cath. IV D5/.45 NS @ 125mL/hr. Vitals normal. Fundus firm, midline, moderate lochia rubra. No redness, swelling to incision. Incision edges well approximated. Urine output normal. Bowel sounds present in all 4 quadrants. Lungs clear bilaterally.Breasts full, colostrum present, pt. is breast and bottle feeding. Clear liquid diet. Spouse present at bedside. Pt. wants to ambulate and is eager to go home. I need help with my wellness diagnosis and interventions. DX: Readiness for enhanced self-care, able to ambulate with assistance. I following an example from Nursing Dx. Handbook by Betty J. Ackley, but I feel like the last part isn't right. I'm not quite grasping the "action or health-seeking behavior that will be enhanced" part. Interventions: 1. Assess patient's balance and ability to ambulate (Teacher wants assessment first) 2. Set goals with the patient My book doesn't spend a lot of time on c-sections, so I'm not sure what is realistic for this patient or what types of teaching (even for long term) I could give to her. Maybe do not lift objects heavier than the baby? Any help is appreciated.

Also, the "Risk for peipheral neurovascular dysfunction related to swelling" came from my med/surg book required by my program, which is from 2010. That may have been the problem.

Please disregard previous post. I couldn't figure out how to change it, so this is what I want to say. Okay this is what I was wanting to know! Thank you, you are a godsend! I wasn't even thinking logically about DVT. It would be due to the 52 year old patient's immobilization after surgery that would cause blood stasis am I correct? He is also at risk for falls. Btw, I meant risk for peripheral neurovascular dysfunction. I didn't realize I left out peripheral. I just want to clarify that there are more important diagnoses to both of these patients; however, my teacher wants our class to stop using the "given" diagnoses, and start trying new ones that apply to our patients, but this specific one threw me for a loop. I don't want you to think I do not assess my patients. I may not know everything to look for, and may have holes in my data due to lack of experience, but I do assess, and try to find their problems, prioritze them, and then make a diagnoses which Esme definately helped me with last semester. Also, I bought Nursing Diagnosis Handbook by Betty J. Ackley. I'm going to order the Nanda DX one next.

I bought Nursing Diagnosis Handbook by Betty J. Ackley. The section under peripheral neurovascular disease just confused me because my med/surge book flip flopped about compartment syndrome and DVT, so I wasn't 100% sure that DVT was represented under that diagnosis. I apologize. I should have clarified my intention for these diagnoses. My teacher just asks for 2 diagnoses for each patient, so at that rate, most of them would be related to lungs or circulation as we have a lot of COPD pts and diabetics, so those are typical priorities. These patients have many more important actual diagnoses, I agree; however my instructor wants us now to explore other diagnoses that are not as commonly used. Both of these patients in my opinion are at risk for inadequate perfusion more so than other patients. I want to assure you, I fully assessed my patients and do realize more fitting diagnoses and other areas for concern, but that isn't what my teacher wants this time around. I just wanted to know if DVT would have better fit into the diagnosis: risk for peripheral neurovascular disease or if I as at least on the right track.

Hello, I had a pt. who was a 91 year old male with right hip fracture and right wrist fracture from a fall, mind you this is before surgery. He was in moderate pain from his hip fracture. His right arm was very swollen in comparison to his left arm. He was able to lightly grip my hand and wiggle his fingers. The pulse was palpable, but due to the swelling was very light. I want to use risk for neurovascular dysfunction related to swelling. Then, I had a 52 year old male pt. with a left hip fracture 3 days post-op from a hemiarthroplasty. He has a history of a stroke 2 years ago, 2 brain bleeds, a craniotomy, and hypertension. He had not ambulated after surgery and was still bed bound. He had pneumatic compression devices on both legs, and was not on any anticoagulant therapy His pedal pulses were strong, legs warm to touch, no redness or swelling in the legs. My concern here would be him developing blood clots because he still hasn't ambulated after his hemiarthroplasty. My diagnosis book confuses me on this diagnosis: Risk for neurovascular dysfunction related to orthopedic surgery, or is there is another defining characteristic that would better describe risk for DVT, or do I just make my interventions about preventing DVT? I thought of risk for injury, but how to I relate that more to DVT? Risk for injury: internal related to ??? Also, can I make ineffective peripheral tissue perfusion a risk for diagnosis?

Grn Tea thank you so much. I always feel like I'm not quite getting it or not paying attention to important things.

I just ordered a nursing dx book yesterday, but it won't be in until next week unfortunately.

I'm working on a care plan for an 8 month old female child who was admitted for broncholitis due to RSV. She was in respiratory distress when she came to the hospital as I was told by the night shift nurse who had admitted the patient 2 days prior. She had audible congestion, crackles, ronchi, O2 sat. 88% and clear,viscous mucus upon suctioning. She had no retractions, and her RR was 44, all other vitals were normal. After suction O2 went to 96%, but she still had crackles and ronchi, and slight audible congestion. I used ineffective airway clearance already, but am debating my next dx. My teacher would like use to travel outside of the fundamental nursing dxs and does not mind if we use risk for vs. actual. I was thinking of using risk for injury related to lack of parental knowledge regarding safety because the mother left the 8 month old infant on an adult bed, not a crib, twice to my visual knowledge while she went out of the room to speak with the nurse and to speak on the phone. I'm slightly lost on interventions. I have: educate parent about use of proper bed for child's age, and educate parent about leaving side rails up when not in direct contact with infant. Any suggestions?

Also, I'm working on getting the Nanda book.