takingcare19

Yes it does! I know what I want to say, and in this case it is the risk for clots but wording it in Nanda is hard, I turned this in and will see what feedback I get! As always, I appreciate the help here! =]

Well, I'd venture to say thrombus? Ok, wait...Thrombus forming on mechanical valve and it doesn't work properly, there fore decreasing cardiac output? And then there is the risk for stroke if said clot broke off? Maybe?

I have a pt that had a mitral valve replacement back in the 80s. He takes coumadin at home, but the last time he had an INR was December. Of last year. =o He comes in the hospital feeling weak, having tarry stools for at least 2 months. His INR on admit was 5.6 and Hgb 4.5. Yikes. The day I took care of him his INR was 1.7, still subtherapeutic. He is on heparin drip and coumadin. I found out he is on Heparin to help bridge him to just coumadin. Ok, I get all this. Now, I was thinking of altered cardiac function r/t subtherapeutic INR and MVR. Would it rather be a risk for thrombus...? I'm just not sure how to say what I want to say, which is - he is at risk for a clot since his INR is not up to par yet. I'm just having a brain block right now I think. -_-

Who knows. The books that they recommend have a goal/outcomes section and interventions with rationale's in them, so maybe that is why? I don't know! =]

I put the stress down in my documentation to support this dx. I am happy to have something right on track! =] =] =] Your book you recommended is very nice! =]

So here is the rundown: 82 y.o. male who came in with c/o chest pain. He was given nitro and fentanyl and given a CXR which revealed cardiomegaly and mediastinal widening with mass like projection. His chest pain is now controlled, and according to the nurse, he would have been sent home if not for the discovery on the CXR. He has + 2 pitting edema both lower extremeties. Hx of CAD, CABG x 3 vessels, a-fib, pacemaker, HTN, PVD, DM2, CKD stage III, anemia. He was given 2 units of PRBS last night as well as 1 unit FFP. INR today 1.45, so he was ok'd for a biopsy (which they let me watch and was way cool). His labs showed anemia. Glucose is uncontrolled, today was 274 in AM, 313 at lunch (this is after being NPO midnight). We held his insulin in AM due to being NPO and he has a rapid response to Novolog with a tendency to drop according to nurse. They suspect lymphoma or lung cancer. When we talked, he went on and on about his family, how he provided well for them, their education, and his excitement of being a great-grandfather in May. He also kept saying, "Just b/c they found something, doesn't mean it is malignant. It may just be nothing at all!" When I did my assessment, I could not find much - he has a band-aid on his toe, he ripped a toenail off the day before, he noted a cough which he noticed today, non productive. He has urgency when he needs to urinate. So, here are the few dx I thought of...my signature question, am I on the right track? 1. Decreased cardiac output r/t altered preload and afterload AEB edema, fatigue, c/o dyspnea on exertion. 2. Activity intolerance r/t imbalance between oxygen supply/demand, generalized weakness AEB reports of exertional dyspnea and fatigue, anemia. 3. Risk for situational low self esteem r/t functional impairment, physical illness, and social role change.

Yes, it sure does! =] Well, at least I feel that way at the moment! Ha.

All Nurses is great! Esme, I got my care plan back, I actually had the words "nice job" written on them!!! Esme knows, I had trouble in Foundations and I'm so stoked to see those words on my care plan! =] I hope I can keep up the good work. Oh, and my nursing dx book came in. I think it'll be great, I'm just worried about interventions and rationale as we still have to list those on our care plans. Lol, so I'll be posting again soon! =] Thanks again everyone, your guidance has been great!

Doh. Well that makes sense. Sheesh. No wonder I felt like I was repeating myself!!

Esme, you are an angel. My list has a couple from your list so maybe I am on the right track this time. Lol. So does this sound goofy: Risk for bleeding r/t bladder cancer, medications (Xarelto, aspirin) AEB voiding 400cc bloody urine, low H&H. Patient will maintain stable vital signs with minimal blood loss by end of shift aeb: - No bloody urine noted - BP will be >90 systolic and >60 diastolic - H&H will be WNL.

And, also, I haven't gotten that book, but I have a little school money left and I just ordered it! =]

School is... going! I did my mental health rotation which was great! Now I'm back on the med/surge floor and my confidence level has already plummeted. Oye. My assessment - her vitals are all wnl. She c/o pain in her chest, makes sense, a chest tube doesn't feel good! Her O2 was 99%, reps 20 and she did not c/o SOB. She has a stooped posture and she is weak, needing a walker to ambulate. She has a-fib, and has a pace maker. When I listened to her heart, I could hear her rhythm was different, the extra gallop in the lube-dub. She had very slight crackles when she exhaled, but she also made a humming/growling noise a lot too, even when asked to take a normal breath. She has not had a bowel movement since 8/28. She had red urine, she has a hx of bladder cancer. Her recent lab showed an elevated WBC, low h&h, high platelets. She is on aspirin, xarelto, iron, protonix, coreg, Celera, buspar. So, With what is going on with her, my initial thought is a breathing problem, but at the time I took care of her, her chest tube was still placed, although clamped, which makes her at risk for another collapse, even with the tube in, right? That is my understanding when I was looking all this up! =] Another thought was bleeding risk, since she is on aspirin and xarelto, but then the anemia comes into play there too in a way I just haven't grasped yet I'm sure! So with all this being said, I feel like she needs the most attention to her breathing and her risk of bleeding... am I totally off base?

I feel a bit stuck on my dx. I have a pt with an interesting situation. She came in a few weeks ago after a fall, she broke her rib causing a pneumothorax. She had an emergency chest tube placed. They have tried twice to remove her chest tube and get her to rehab, but her lung keeps collapsing. She smoked x 50 years, recently quit this year. She has emphysema. She is anemic r/t bladder cancer and sever hematuria. She has a-fib with a pacemaker placed a few months ago. When I saw her this week, she was on her 3rd chest tube. They had it clamped to see how she tolerates it, and planned to remove it. They day I cared for her, they still had not removed the tube. Her vitals were wnl, her bp was a bit low, but she had just received HTN medication. I was thinking of going with Ineffective breathing patter r/t pain in left lower lobe from chest tube AEB shallow breathing and pt c/o pain. My teacher asked me to look for problems that could be serious, cause death with her. I just feel a bit lost on this one, she has been released for a week now, they have just been trying to make sure she can tolerate her chest tube being removed. An outside perspective would be appreciated! =]

I feel a bit stuck on my dx. I have a pt with an interesting situation. She came in a few weeks ago after a fall, she broke her rib causing a pneumothorax. She had an emergency chest tube placed. They have tried twice to remove her chest tube and get her to rehab, but her lung keeps collapsing. She smoked x 50 years, recently quit this year. She has emphysema. She is anemic r/t bladder cancer and sever hematuria. She has a-fib with a pacemaker placed a few months ago. When I saw her this week, she was on her 3rd chest tube. They had it clamped to see how she tolerates it, and planned to remove it. They day I cared for her, they still had not removed the tube. Her vitals were wnl, her bp was a bit low, but she had just received HTN medication. I was thinking of going with Ineffective breathing patter r/t pain in left lower lobe from chest tube AEB shallow breathing and pt c/o pain. My teacher asked me to look for problems that could be serious, cause death with her. I just feel a bit lost on this one, she has been released for a week now, they have just been trying to make sure she can tolerate her chest tube being removed. An outside perspective would be appreciated! =]

Wow, thanks! So you work longer than the 12 hour shifts? Money is a side note. I like the idea of being in so much direct control over your patient, if that makes sense. Patients put their lives in your hand, but this just takes that trust up a level, and I like that idea. It's a hard feeling or want to explain! I can see how it would be an odd transition to go from pretty experienced in ICU to being told how to do basic (for your) tasks! Again, thanks for your viewpoint. I appreciate all I can learn! =]