Christian_SN

i start in the cardiac intervention unit ... during the day. during the day might be a bit too much for a new grad??? the nurse manager feels confident that i will do 'just fine' but ... i question everything and pay a lot of attention to details...... Is this bad? Please give your input, and thanks :)

Clean the Yard and House. Talk with the children and husband. honestly ... i am bored out of my mind and keep going to study ... then realize that i do not NEED to pick up a book. crazy NEW Life we are livin'?

Clean the Yard and House. Talk with the children and husband. honestly ... i am bored out of my mind and keep going to study ... then realize that i do not NEED to pick up a book. crazy NEW Life we are livin'?

use this format: Orientation: person, place, time, and event. Are they awake, alert, and oriented? Skin: Check turgor, edema od dependent areas, temp, moisture/dryness, capillary refill, color, lesions, hair distribution, campare R to L sides. Head/Neck: note size, shape, symmetry of facial features; PERRLA; color of sclera/conjunctiva; palpate maxillary/frontal sinuses for tenderness; mucous membranes (moist, pink, intact); visualize pharynx and tonsils if indicated; tongue midline; palpate lymph nodes; check for JCD; apparatus (NG tubes, O2 mask, tracheostomy, etc) Extremities: ROM bilaterally; strength of upper and lower extremities; pulses; sensation; Homan's sign; check for JVD; apparatus (IV's, restraints; dressings; drains) Chest: Auscultate breath and heart sounds; note retractions or use of accessory muscles; note chest symmetry; palpate for masses; breat exam if indicated; apparatus (telemetry; chest tubes; CVP lines; dressings; drains) Abdomen: note scars; herniations; bowel sounds in all 4 quadrants; palpate for massess and tenderness; is abdomen firm/sodft; CVA tenderness; apparatus (G tube; ostomy; dressings; drains) Perineum: note drainage; hemorrhoids; apparatus (catheter) Equipment: note all monitors and record readings (IV pumps and amt of fluid infused, solution, and rate of infusion; EKG readings; feeding pumps; etx) Drains/Dressings: note site of dressing and amt of drainage; on catheters note amt of drainage and color of urine Doctor Visits: note who the doctor is, time of visit, what he/she did Procedures: note all procedures performed and what time (catheters, NG tubtes, trach care, dressing changes, etc) Safety: bed locked and in low position; HOB side rails x 2; call bell within reach) Patient Complaints: document all complaints/statements in their words using quotations then write: hope this example helps you ... my teachers also say i can tell you the amount of hairs on their head. hee hee... i have ALWAYS gotten an A for my head-to-toe and narr notes. i love to do them. let me know if you like? 0700 Received report from J RN to J RN at 0700. Side rails up x4, call light within reach, bed in low position and locked. HOB elevated to 30 degrees. Name/id, PCN allergy band on right lower arm with easy view. Admit to ER on 02/07/2006 due to SOB with dz of CHF. Lethargic LOC, A&Ox3 responsive to speech and does follow commands. R 3mm, L 3mm. PERRLA moist, pink, intact mucus membranes. Lips moist with Vaseline per md orders. No mouth order. Has majority of teeth, no loose teeth, no dentures. Swallowing and gag reflex intact. Does not have any hearing loss, thus no hearing aids. Does hear whispers bilaterally. Attempts to speak. GCS of 15 out of 15. Comfortably resting facial pain scale indicated no pain due to no grimacing, no guarding behaviors, or verbal reports indicating pain. Morphine 2-5 mg IV Q4H or PRN per MD orders if needed for pain. Hand grips are equal bilaterally but weak. No tremors or seizures. Lorazepam 1 ml Q2H PRN per MD orders for sedation. Levothyroxine 125 mg po per md orders for history of hypothyroidism. TSH lab value is 6 mU/l for a normal level of 6-10. Tracheal position is mid-line. No JVD. Cough is nonproductive. Moderate amount of thick yellow secretions noted upon suctioning. Oral endotracheal tube intact 7 mm with 22 to teeth on right side. Ventilation set is HFV 500, FIO2 40%, R 10, PEEP 7, PS vent 8. ABGs reveals no imbalances at this time. No indications of labored breathing with use of accessory and abdominal muscles. Rales and crackles auscultated bilaterally. No complaints of SOB. Lasix 60mg IV BID per MD orders. No presence of subcutaneous emphysema bilaterally. Apical HR of 112 b/min. irregular with no presence of pulse deficit. Atrial flutter-fibrillation noted on ECG monitoring system at bed side. All leads for telemetry are in correct placement, with no signs of redness or irritation. BP was 117/45 by non-invasive cuff located on right upper arm, with a pulse pressure of 72. CVP monitoring via central line of 8 (6-10). Normal S1/S2 heart sounds upon auscultation at apex. Normal S1/S2 heart sounds upon auscultation at base. No murmurs or rubs auscultated throughout bilaterally. Multiple P wave is present and upright 300. Labs revealed PT of 25.7, INR of 2.2. INT placed on 02/07/2006 size 20 in left hand no redness or verbal reports of pain or any other signs of infection, dry and intact. Responds to teaching on CHF signs and symptoms, such as daily weights, feeling of SOB. Responds to teaching of diuretics (lasix) to reduce pulmonary edema. Bed-side monitor alert levels are as follows: HR hi-135 lo-65, NIBP sys hi-155 lo-95 dia hi-100 lo-50, O2 stat hi-100 lo-92. Volume for alarms are at 90%. Side rails up x4, call light within reach, bed locked in low position, HOB elevated to 30 degrees, Resting comfortably. door open with easy view. 0900 VS are as follows: HR 100, RR 15, BP vie non-invasive cuff 117/45, temp 100F, O2 98%, CVP 10. Atrial flutter and some runs of atrial fibrillation observed at bed side monitor. Output via foley is 75ml non-concentrated, yellow, clear urine for a total of 175 starting at 0600. Comfortably resting facial pain scale indicated no pain due to no grimacing, no guarding behaviors, or verbal reports indicating pain. Side rails up x4, call light within reach, bed locked in low position, HOB elevated to 30 degrees, Resting comfortably. door open with easy view.

thanks for this post. i was looking as well. the day is almost here ... can you believe it! :)

1. primary care-giver of my father until is death (dec 1, 2002). my father was 45 yrs old when i was born ... he always had heart problems ... being a RN was written in stone before i was born. hee hee 2. education is a must in my family (for my father) 3. cardio/ccu is the only type of rn i want to be 4. money comes and goes ... i make the same pay-check ... if i do not care or do care for my patients... i want to make the most of my time FOR my patients ... rn_s rep has gone down hill ... i want to bring care back into nursing

yeppers, i got an 'A' too! Chem classes were the only classes that ever challenged me. - that is until Nursing school !!

CONGRATULATIONS !!! Starting on my 2nd semester of classes in Nursing school, I have been using the book(s) and cd(s). I am now going to graduate in May. In our school we had to buy Saunders Nclex-Rn with our Med-Surg class. I am glad to know that our instructors are thinking! Thanks for the advance and I’ll continue to use Saunders. Was there any question of Herbals and interactions?

a great book is: nurse's pocket guide diagnoses, interventions, and rationales. 9th edition by doenges, moorhouse, and geissler-murr. this is one on my care plans, not the best one, but i hope it helps you learn. risk for diagnosis will NEVER have an AEB (as evidence by) but will have an R/T (related to). example: fluid volume deficient r/t excessive losses through normal routes AEB disrrhea x5 days. hope this helps you. assessment and evaluation signs and symt should always go with your Dx. (care plan is not a good example of this) your outcome should always have a time frame. goal can be met, ongoing, or not met and give AEB under interventions: always give a time frame of when to do it. example PRN or per MD orders. your interventions should always match you outcome. if you write for the outcome that: pt verbalizes understanding of Dx then have all interventions that Teach about the Dx. good luck! you'll get it. Assessment Depressed cough reflex, presence of dou tube as of 4/22/2205 at 1100, BD (nutrition) Ensure bolus and medications as ordered by physician, history and complaints of impaired swallowing, inability to clear secretions or any obstructions from the respiratory tact, productive cough with suction as needed, airway is clear at the moment with no vomiting, call light with in reach, HOB elevated to 45 degrees, side rails up x4. Objective data: 3/11/2005 Patient admit for right sided weakness and impaired swallowing. Refuses to swallow. Patient has decreased gag reflex. Pt will follow commands as needed for procedures. Nursing Diagnosis Risk for Aspiration related to reduced impaired swallowing Desired Outcome Throughout the hospital stay, the patient will: Maintian patent airway Reduce risk for aspiration as a result of ongoing assessment and early intervention. Nursing Intervention Monitor level of consciousness Assess cough and gag reflexes Monitor swallowing ability (cough, clearing, residual, regurgitation, choking) Elevate HOB to 45 degrees at all times Check for residual every 4 hours Explain to care-giver the need for proper positioning Assess for pocket food Ticking liquids and medications if sou tube was not in placement for feedings and medications Turn head to side Rationale Increases risk for aspiration Increases the risk of aspiration Increases risk for aspiration Reduce chance of aspiration High amount of residual indicate delayed gastric emptying and cause distention of the stomach leading to reflux emesis This decreased the risk of aspiration Food can get into the throat To ease swallowing liquids and medication Evaluation Depressed cough reflex, presence of dou tube as of 4/22/2205 at 1100, BD (nutrition) Ensure bolus and medications as ordered by physician, history and complaints of impaired swallowing, inability to clear secretions or any obstructions from the respiratory tact, productive cough with suction as needed, airway is clear at the moment with no vomiting, call light with in reach, HOB elevated to 45 degrees, side rails up x4. Goal Met As evidence by: Nurses notes states with observation of patient: patent airway, early intervention and assessment decreased risk for aspiration.

Care plan that I wrote, hope it helps someone. It is not one of my best, but hope it helps! Aeb can "Not" be used with an at "Risk for" dx. Assessment and evaluation must go with the nursing dx. Nursing interventions must have time period (example is prn or q4h per md order) AssessmentSudden onset; shaking chill; rapidly rising fever of >101. Cough productive of purulent sputum (pink, thick). Pleuritic chest pain aggravated by respiration/coughing Dyspnea on exertion, no nasal flaring, or use of accessory muscles. all pulse sites palpable. IV antibiotics administered to patient as ordered by physician of vancomycim 0.5gm q6h Oxygen per cannula, 5L with nebulizer q4h. Respirations 28 and shallow. Apical pulse is Weak at rate of 92. Pale and dry oral mucosa. Diaphoretic. Checks flushed, and hot. Inspiratory crackles in upper and lower chest. Fatigue and anxiety expressed. Non-smoker. no Hx of asthma. Hx of chest cold x2 weeks. Husband not at bed side. Side rails up x4. Call light within reach. Nursing DiagnosisInfection related to invading bacterial/viral organisms secondary to pneumonia as evidence by sputum pink and tick, Dyspnea, crackles in upper and lower field. Desired OutcomeThroughout the hospital stay, the patient skin will: Improvement of infection aeb , normal WBC, negative sputum culture on repeat culture Nursing InterventionAssess for predisposing factors; medication chronic illness Assess vital signs closely monitoring temperature fluctuations Obtain freash sputum for gram stain, and culture and sensitivity Monitor gram stain, sputum, culture and sensitivity Monitor WBC count Assess hydration, Rationale High doses of some medications have reduced resistance to infections Continued fever may caused by drug allergy, drug resistant bacteria, super infections, inadequate lung drainage. Determines correct antibiotics coverage for pt Determines correct antibiotics for resistant bacteria > levels indicate infection Water loss is > with fever. EvaluationNo change in the following: Sudden onset; shaking chill; rapidly rising fever of >101. Cough productive of purulent sputum (pink, thick). Pleuritic chest pain aggravated by respiration/coughing Dyspnea on exertion, no nasal flaring, or use of accessory muscles. all pulse sites palpable. IV antibiotics administered to patient as ordered by physician of vancomycim 0.5gm q6h Oxygen per cannula, 5L with nebulizer q4h. Respirations 28 and shallow. Apical pulse is weak at rate of 92. Pale and dry oral mucosa. Diaphoretic. Checks flushed, and hot. Inspiratory crackles in upper and lower chest. Fatigue and anxiety expressed. Non-smoker. no Hx of asthma. Hx of chest cold x2 weeks. Husband not at bed side. Side rails up x4. Call light within reach. Goal NOT met As evidence by: No lab values obtained for ABG, WBC, sputum culture.

pt has PVCs

i have a tat on my right upper arm - big. i have hated it ever since i got it. i have had one laser treatment on it and have 4 more to go - but nursing school is $ so it has to wait. i have been wearing 3/4 ro long sleeve shirts all year around. ugg. don't show it , cover it ... while in school

Update: Most of the gas stations are still out of gas in Mobile and Baldwin county. In surrounding areas where Katrina hit there is no gas b/c of either lack of power or gas. If there is a line it is still at least a 6 hour wait. Most people in surrounding areas (Mobile and Baldwin county) are renting trucks and asking people to bring supplies to take to Mississippi (Gulfport, Biloxi, and surrounding areas). In parts of Mississippi (where there is no news persons accept for here) there are reports of people drinking the flood water or drinking from swimming pools, babies with no diapers or formula. So all day we have been at the Alabama and Mississippi state line filling up trucks with supplies. People have been bringing every thing you can think of even washer and dryers (why? No power and house to put them - but nice). We had a news reporter break down and cry on air. Health care person in Florida have put together meds, rented a bus, and is heading to Mississippi to take care of people. 50% of Mobile has power now. 75% of Baldwin county has power. Every one on food stamps have been issued their food stamps early (on a card they hold - they say). And free food stamps for the people wanting to stand in line. As soon as a wal-mart fills up - it is bare once again by night. http://www.hurricanehousing.org is a web-site for people donate their homes to people that have lost their home. Of course, you can set your own price per month - if you want. Others that want to house a family in their home can contact the police department. I have a friend that has taken in a family. Most of churches have opened up to house people that have no where to go (as with the shelter stated in an earlier post). Today has been a good day, knowing that you are helping others that really need help really helped my spirit today. I guess that I had time NOT to think about my home and friends. Thank you all for your love (again), you love and care really is the best. Donating money to help others instead of a vacation ... um ... touches me ... deep within. All of you are truly going to be the best Rns ever.... Such a big heart... such kind words. You'll always be in my heart ... the heart and soul I felt as I read each post from you all ... will never be forgotten. As always, I'll keep you updated.

kayel & BSNin05, thank you so much for your words full of love. i cannot help but to cry when i read your heart-felt care. like i said 'i cannot place my words together to even tell you how i feel (for me and others). i have been on the net stayin busy. thank you both so very much. i'll keep you informed of what is going on here. it really helps to talk about all of this in my heart. thanks for being there for all of us. an e-mail from a class-mate that is working at a shelter (like i am): Listen to this. The salvation army has been feeding the three hundred folks that are still in the shelter here and tomorrow the evacuees don't know it, but the salvation army has been redeployed and are moving out and taking all their food with them. So now the people that they've brought in here will have to be fed and clothed by the local churches. So we've just discovered we'll be responsible for feeding 300 people and the grocery store is empty.

It has been very hard and difficult. Despair and depression watching all that is going on around me. I got power back today. Have no food but have water. There is no gas anywhere. If a gas station has gas then it is a $5 limit!!!! People are in lines for up to 10 hours for gas. President Bush came to my town today. A woman was crying b/c she had lost everything and Pres Bush held her ... he allowed her to cry on his shoulder. I was in tears myself. My house is livable but barely. I have not heard from my friends in New Orleans, I can only pray that they are well .... I can only look at the positive b/c losing that many friends is truly heartbreaking. Words do not come easy to me at this time! One day at a time, I guess. when me nursing school opens up, we are going to accept nursing students from other states... thank the Lord they have a school to go to. Viral Meningitis is going around. (not bacterial). There are many cases here. Again I am at a loss for words. Please keep all of us in your prayers! PLEASE. Thank you so much for this post and all the care and love. :thankya: :heartbeat