I have a careplan due Monday, and I am desperate for help!! I have to have an actual nursing diagnosis and a potential diagnosis. My potential is no problem. I am going with "Risk for injury related to anticoagulant use." My actual, on the other hand, is causing me quite a bit of difficulty. I need some advise. My pt was admitted with abdominal pain et subsequently diagnosed with a superior mesenteric vein thrombosis et a portal vein thrombosis. By the time I saw her (a few days later) her pain was a zero. That knocks out pain as a diagnosis. My next instinct was to go with Ineffective Gastrointestinal Tissue Perfusion, but she didn't seem to really meet the criteria for that diagnosis either. I will list her main problems: she had to be transfused with 2 units PRBCs due to anemia; she is on anticoagulant therapy; rates pain at zero; history of ASHD, HTN, stable angina, anemia, hemoccult positive stool, seizure disorder, et chronic ASA use at home. Her past surgical history is unclear, although she apparently had a hysterectomy sometime between 18-30 years ago. She mumbles when she speaks, and then she will speak clear at other times. (78 y.o. female). She is a very poor historian. Vital signs stable. Does have generalized weakness. Voids without difficulty. Bowels sounds normal X 4 quads. No hx of diarrhea/constipation prior to admit, however, some mild diarrhea since admit.
Any suggestions would be greatly appreciated.
Quote from icesk8ie
My suggestion would include Fluid Volume Deficit for both the diarrhea and the fact that her hemoccult was positive, indicating some bleeding in the GI tract. That's all that I can think of for now. Good luck!
made a mistake - sorry
Last edit by JENRN2BMICHIGAN on Apr 3, '04
: Reason: mistake