atm24

I'm thinking something along the lines of ineffective airway clearance r/t decreased lung expansion secondary to pleural effusion aeb CO2 level of 30. I'm not sure if the CO2 level is correct evidence for that diagnosis, though. I'm also thinking about acute pain r/t obstruction of the pancreatic ducts secondary to pancreatitis aeb verbal report of pain of a 4 on a scale of 0-10.

Yes, the patient was in pain. She complained of pain of a 4 on a scale of 0-10 in her midback. She stated that she had been experiencing that pain for the past 2 months. She was able to move herself and do her ADLs without assistance. She was able to get out of bed and walk with no help. She was on meds for depression. Everything with the integumentary system was fine. For cardiovascular system the rhythm was sinus tachycardia with a rate of 109. Oxygen via NC of 2L/min. Non-productive cough. Wheezing at left lung base. Diarrhea twice two days before clinical. Hematuria which pt stated has been occurring since childhood but causes no problems and the doctors do not know why it occurs. PERRLA. Good reflexes. Score of 15 on glasgow coma scale. Muscle strength 5/5, bilaterally symmetric with full resistance to opposition.

Hi! I am working on a care plan and I am having a difficult time coming up with 2 nursing diagnosis. My pts main problems are pleural effusion and pancreatitis. The RR were within normal limits. O2 was 30. She is a smoker but was on nicotine patches while in the hospital. Wheezing on left lung base. A CT showed significant left sided effusion, small right sided effusion, mildly enlarged heart, abnormal liver and likely pancreatic pseudocysts. BUN was low, glucose was high, albumin was low, ALT was high. Any help would be appreciated! Thank you so much!