Harley Nurse
Full Member
Karma: 4
Posts: 185
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« on: April 11, 2008, 03:23:01 PM » |
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I woke up at 5:00 AM. Took my shower, put on my makeup, and put my hair up. I ate a Clif Bar and some fruit and I am ready to go. I got to the hospital lobby at 7:00. Again, Diane, the CA, promptly takes us to where we have to go. We go to a little conference area that they call the “hub” and she looks at our calculators, drug books, and nursing diagnosis handbooks. We then go off with our CE for our first PCS.
Thank goodness for my sweet Georgine. She truly made me feel so much better. She took me to an empty nurse’s station and I began my planning phase. I prepared my grid and gave her my form and she accepted my care plan. Whew! I then went to the primary nurse and she was nice but she had very little info. She kept apologizing. I was so glad that I had gotten to look at the chart the evening before.
Georgine rounds up all of the necessary equipment and off we go! I love this hospital because every room has gel at the entrance and most rooms have a sink there also. Also, they have a pull down shelf that you can use to chart on and you don’t have to use a barrier. Anyway, my bed rest patient is sitting in a chair! I am kind of panicking and Georgine tells me not to worry, she will change it. I am still to reposition X 1 with assistance of 1. OK…so I gel my hands and do all of my 20 minutes checks and go through my little drill. I explain to her about the I&O and ask her not to throw away any containers. I also note how much water is in her pitcher (again…I love this place…the pitchers are clear with measurements on the side). She is a very pleasant woman. I couldn’t have hand-picked a better patient.
I get ready to obtain my vital signs and the phone rings. Someone who she hasn’t talked to in a while. Great…lol…so…we wait and wait…Georgine must have seen my anxiety and she tells me that she will add the time on to my PCS, so that made me feel better. I just charted my 20 minute checks and Georgine and I made some small talk. Finally, about ten minutes later, she hung the phone up. Now…on to the vitals. She was a S/P left mastectomy and she had a hep lock in her right antecubital and I did note that the staff had been obtaining BPs on the right side. I also confirmed this with the patient. I am getting ready to pump up her cuff and here comes the breakfast tray. Good grief! The patient tells me that she knows I need to take her vital signs and I told her that I would try to get them quickly so she can eat in peace. I attempt to take her BP and I can’t hear a thing…they had taped her hep lock site so much…Yikes….I wait a few minutes and I take it again. Still can’t hear. Crap! I am wondering what the heck I am going to do. I tell Georgine that I wasn’t comfortable with it and I am going to take it again in a just a few minutes. She smiles and says that is OK.
Just then another CE comes in and asks if she can switch stethoscopes with us because another student said that she was having trouble hearing. Great…I think….I am probably going to get an even worse stethoscope. Georgine tells me that we will get another one if I am not comfortable with that one. So…I take my BP for the third time…and hear it just fine. Take all of my other vitals and declare them…she told me to continue. Yippee!!
I go to obtain her meds and let her finish her breakfast. She has three PO meds…Atenolol, Potassium, and Nexium. Easy. I just have to have her BP and heart rate for the Atenolol. Go back to the patient’s room and give the meds after checking her ID band. I then assessed her lungs while she was still sitting in her chair, gave her a tissue for any possible secretions, and had her to perform three cycles of deep breathing and coughing. I then reassessed her and helped her back to the bed. I asked her if she felt like she was increasing in her strength and endurance and she informed me that she really never had any problems with strength and endurance. Well, there goes my outcome for my diagnosis. I performed her neuro assessment and checked all of her I&O. Did my exit checks out loud…SR X 2, bed low and locked, phone in reach, call light in reach, glasses on patient, ask if patient needs anything, thanked my patient for allowing me to participate in her care, and washed my hands.
I went to give report to the primary nurse and then Georgine took me back to the empty nurse’s station to complete my evaluation phase. I used my grid to document on all of my areas of care and then I asked Georgine about the outcome on the impaired physical mobility diagnosis. I showed her that my outcome statement was that patient would report an increase in strength and endurance, however, the patient stated that she never had any problems with that, but it was documented on her chart(thank goodness) that she had decreased strength. So I wanted to change the wording of the outcome statement to display instead of report an increase in strength and endurance. She said that it was fine and since I discussed it with her, that I could just change it on the original form and I didn’t have to complete a revised form because it was just that one word….groovy. I am feeling better now.
I chose impaired physical mobility as my priority diagnosis. My outcome was met. My evidence was the patient was able to ambulate from the chair to the bed with assistance of one without any c/o dyspnea, dizziness, or pain. NI 1. Assess level of mobility—effective—Upon assessing level of mobility, it was noted that patient was able to ambulate from the chair to the bed with assistance of one without any c/o dyspnea, dizziness, or pain. NI 2. Assist to reposition X 1 --- effective---Patient was assisted to ambulate from the chair to the bed with assistance of one without any c/o dyspnea, dizziness, or pain. My rationale was: According to Maslow’s Heirarchy of needs, adequate physical mobility is a basic physiological need. Not maintaining adequate physical mobility can predispose the patient to a variety of complications including respiratory complications, muscle atrophy, and impaired skin integrity and if not managed now, could deter progress to achieve outcomes and could prevent the patient from participating in their plan of care and could prolong patient’s hospital stay. I checked over my grid one more time and I handed Georgine my forms. I only had about 5 minutes left anyway. She was gone about 3 or 4 minutes…the longest of my entire life…lol! She smiled and said you passed! She took me back to the hub where Diane, the CA come and took me down to the lobby for a little break.
I wasn’t really hungry, but I ate a Clif bar and an apple. I am so excited, but nervous. After about 25 minutes, Diane came and took me back to the hub where I was handed over to my next CE, Kristina….
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