trudreamer_88

Unfortunately it was our first day on the floor for this Semester so we were not able to do out own assessments this time. We were only allowed to do AM care and vital signs. She needed help getting out of bed and into a chair, but she was self care. She cleaned herself up without any problems. Because it was only a few steps from bed to chair the only thing i noticed is she was a little slow at moving. She didn't get SOB moving from bed to chair and back. She was on tele but the monitor wasn't in her room it was the portable one people in a room watch.

Thanks that helps. Cause she talked about the pain a few times while I was in there. I kept skipping over it as a possible dx because it wasn't why she was admitted so I figured I wasn't allowed to use it.

Can I do pain? The pain is from an old injury and not related to why she was admitted to the hospital. I did risk for injury because she was on a Heparin drip and the nurse kept telling her to stay and bed they didn't want her to fall.

I need some help coming up with a 3rd Dx for my pt. The 2 I have completed so far were Risk for decreased cardiac output and Risk for injury. I can't come up with a 3rd for the life of me. Here is ALL the pt info I have written on my pt research sheet. I wish I had more but I did exactly as my instructor asked which turns out to not be enough. 86 yr old female; Self care Current dx: nose bleed, rapid atrial fibrillation PMH: stroke, bilateral cataracts, atrial fibrillation/flutter, hypertenstion, diabetes, hypercholesterolemia, osteoarthritis, lymphedema, breast cancer, colon cancer PSH: catract sx, colectomy, partial thyroidectomy, carotid endarterectomy, hysterectomy, joint replacement, R. mastectomy, R hand ORIF due to fx Social hx: lives with family, no illicit drugs, tobacco or alcohol abuse Labs: RBC (4.51) Hgb (13.3) Hct (40.1) WBC (5.9) Lymphs (39.9) PTT (112.8) PT (11.3) INR (1.0) Glu (131 H) BUN (13) Creat (0.9) eGFR (74) Na (139) K (3.6) Cl (104) CO2 (28) Mg (1.6 L) Ca (9.2) CK-MB (0.6) Troponin I ( Vital Signs 8am: T: 97.6 BP 153/67 Resp: 20 SPO2: 94 on room air Pulse: 70 Pain: 7/10 (L shoulder from old fx) Vital Signs 11am: T: 97.2 BP 121/56 Resp: 20 SPO2: 97 on room air Pulse: 68 Pain: 7/10 (L shoulder from old fx) Diet: Cardiac soft Meds: Insuling Lispro Humalog, Pantoprazole (protonix), Pravastatin Sodium (pravachol), Saxagliptin HCL (Betapace), Diltiazem (Cardizem) Drip, Robitussin, Heparin Sodium Drip, Morphine Sulfate