Reflective Journal

Patient Description

– 55-year-oldfamale, admitted on 02/07/20 with Toxic metabolic encephalopathy

-history of alcohol

-Wernicke’s syndrome

-anxiety

-depression

-GERD

-Hypertension

-bronchitis

-Esophageal varices

Allergies:

-KNDA

Nurse of the future competency brief comments: please see attached PDF to discuss this part,

Teamwork and collaboration

Please use appropriate nursing diagnosis using the Gordons functional health patterns and nursing interventions.

Nurse diagnosis

-Risk for urinary tract infection related to presence of indwelling urinary catheter.

-Risk for impaired gas exchange related to pneumonia/atelectasis

-Risk for falls related to impaired physical mobility

A little about the patient:

Patient took too many clonidine and came to the hospital confuse, left side facial droop. Patient was intubated on 2/07/20 and was extubated on 2/09/20. Patient had a head CT. Patient has no strength on either hands and legs. Pt makes an effort to push with her feet. Pt responds with verbal communication. Urine output is low. Lasix was given but output continues to be low 160ml. Potassium is low 3.1. Potassium was given. Pt is hypothermic 96.5, heart rate 77, respirations is labored, bronchi , BP 132/88. No skin issues. Pt cannot cough. Decerebrate posture. Pts family wanted her to be transfer to Mass General.

Reflective Journal

1. Pt’s family wanted to transfer Pt to Mass General. But Attending Doctor made a comment that would not be safe to transfer Pt and mentioned that whatever treatment she was getting in Mass General could of being done in there too. Pt’s husband expresses the concern to me and the nurse. We explain to him that the Pt need it to go to Mass general for neuro ICU due to the patient was not awaking and she was not on sedatives no more.  

• Pt’s husband was very caring and really concerned with his wife. He was trying to be present in all the rounding’s and was always asking questions.

• Teamwork and collaboration

• The importance of understanding Pt’s wishes and decisions of dying and how to give quality care

• Doctor and nurses could of get in an agreement before talking to the pt family and take in consideration the family decision to transfer the patient.