Help with Care Plans

I could use some help...my final care plan is due tomorrow from last nights patient. I need diagnoses for each system, as well as 4 priority diagnoses for her problems...I have a few in mind here, and am working on it..but this thing is worth 150 points out of 300 needed to pass!
49 yr old female:
Admitted for acute abd. pain, nausea, vomiting. Diagnostic laparoscopy performed on day 2 of hospitalization for partial bowel obstruction, lysis of adhesions...5 small incisions in abd.
Surgical hx includes: 2006 gastric bypass
Spring 2008:Hernia repair (5 areas) and cholecystectomy at that time.
Summer 2008: Appendectomy
Medical Hx: Hypertension, GERD, Migraine headaches, Depression. States she was told she had a slight "heart murmur"-but does not require SBE prophylaxis...nothing listed in her chart about this. Weight loss of 85 lbs since gastric bypass surgery, 6 lb weight loss since hospitalization (4 days)
states she follows the Southbeach diet at home.
Meds include Protonix, Zoloft, Norvasc, Multi vitamins at home. (hospitalization includes zofran, dilaudid q2h prn, heparin therapy)
She requires and requests pain meds every 2 hours...
Foley d/c'd today, voiding
VS BP:135-69, Pulse: 64, Resp: 20, normal, lungs clear, Pulse ox 95% RA.
She smokes 4-6 cig./day
Labs:Abnormals only
RBC: 3.75
HGB: 10.4
HCT: 31.0
RdW: 15.8
PLATELET: 235
NEUT ABS: 6.9
LYMPH ABS:0.8
NEUT: 87.4
LYMPH: 10.0
Fasting Glucose: 132--only time it was elevated
She was A&O xs 3--pain averaged 7-8, and after Dilaudid, 5 at best.
Ambulating, voiding, BM day 2 post op
nd: Acute Pain? Nutrition less than requirements r/t bypass, Body image disturbed? Readiness for enhanced nutrition? Anxiety? R/f unstable glucose? R/f Infection r/t incisions? Does smoking come into play here for lungs? what about ND's for systems w/ no problems! Interruption in family process? (married, 1 child) ugh! I gotta get working on this...will be good to see your responses and if I'm on the right track!

Step #2 Determination of the patient's problem(s)/Nursing diagnosis - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use –

1. Acute Pain?
   • Better: Acute Pain R/T abdominal distension
     • abdominal pain
     • last BM 2 days ago
     • pain averaged 7-8, and after Dilaudid, 5 at best
2. Nutrition less than requirements r/t bypass
   • Better: Nutrition: less than body requirements R/T inability to ingest adequate amounts of food secondary to gastric bypass surgery
     • 6 lb weight loss in past 4 days
     • nausea
     • vomiting
3. Deficient Fluid Volume R/T fluid volume loss (these are symptoms of anemia)
   • RBC: 3.75
   • HGB: 10.4
   • HCT: 31.0
4. Impaired Tissue Integrity R/T surgical intervention
   • 5 small incisions in abdomen
5. R/f Infection r/t incisions?
   • Better: Risk for Infection R/T surgical intervention
   • NEUT ABS: 6.9
   • LYMPH ABS:0.8
   • NEUT: 87.4
   • LYMPH: 10.0
6. Risk for Injury R/T anticoagulation (on heparin therapy)

Hi Daytonite,
I had a pt today who had GBP surgery 7 years ago. She was hospitalized b/c her primary care physician requested she get blood. Her H&H levels were low.
Do you think I could use #2 or #3 from you list above ? I am having trouble because I have no s & s except her lab values for H& H. By the time I met her she already received blood and said she felt great. Not sure how to go about a care plan for someone who does not seem to have any trouble. They wanted to run some more test on her for fibroids . She also had some gouty issues which is why she went to see he PCP in the first place. She says she eats well and has not had any problems since her gastric bypass. can i do a care plan for imbalanced nutrition even though I am not sure why she is anemic? Anemia apparently "runs in her family" ??????
help
thanks
chicagrl

Thanks Daytonite!

The problem is , I don't have any answers. I was only with her for about 5 hours this am. She had just finished the blood transfusion and SAID she felt better - they drew blood to check her levels but I don't have the results.

She had a painful swollen ankle previously, her uric acid levels are in normal range but I guess she good still have gout - they don't really know. She does not currently have and S&S for gout.

She was going for some type of gyne stuff to see if there were fibroids. She did not complain of any symptoms, has not had any S&S either but they are trying to rule everything out.

Vitals, all within normal ranges.

Don't really know where to go with this....