Teri Martin tmfnp@aol.

com 518 852 5847 physical assessment and observation, the rest is subjective defining characteristics are SIGNS AND SYMPTOMS and what they are related to. Nursing interventions and classifications. Oh that is not working and why not... CARE PLAN-both subjective and objective... (marielle-never lead your patient) brain knows because of CHEMISTRY. Objective data-EKG/vital signs/blood work/troponin levels/BP/ priority nursing diagnosis-potential for altered gas exchange....risk of falling...not every patient with an MI has chest pain and not every person with chest pain is having an MI 6am tuesday critical thinking and med sheets, today critical thinking only. ENDOCRINE system- diabetic and thyroid, diagnostic POST CONFERENCE...color white, ashen, grey, a&o x1 not talking or verbal , pulling eyelid down for anemia, pale, mucus membranes dry, mouth dry, chest had wheezing and ronchi, irregular heart rate...on vent/trach/and NURSES NOTES: Patient Awake, nonverbal, responsive to touch, nonverbal, seemed agitated the more people who came into the room, 45 degree fowler (neuro) irreg heart rate, apical pulse irregular, popliteal strong, (cardio) scar down midline- cabg- possibly cardio arterio bypass graph, patient trach to vent ...(settings...) (((front is upper lobes and back is lower lobes))) ronchi heard in all four lobes, cleared after suction, thick yellow sputum. NURSING DIAGNOSIS- INEFFECTIVE AIRWAY CLEARANCE (RONCHI WHEEZE IS MUSICAL, rales and crackles are the same thing, fluid in base of lung or sound of small airway with sticky sputum. Lungs cleared after suctioning... if it didn't work sometimes call on respiratory therapist. GI didn't listen to bowel sounds-JPEG- in jejunum 1.2 cal//cc glucerna lactose and gluten free, 60cc/hr, was jpeg clean, site clean??? if you cleaned what you cleaned it with, stoma? Clean? Pink? How do we check placement? Usually listening, foley(URINary) clear yellow 11000 ml. Pedal pulses... skin integrity. 4 ulcers, 1 on sacrum stage 2 going into 3 upper back stage 2. write where size is progressing or not, barrier crme ornot. SHEARING FORCES; a bed sore starts on bony prominence, pressure down bone to matress , can be prevented. BY PROMOTING CIRCULATION , he was movng but only one way. Resting after oral care...looked much better.