Hope there is someone up tonight who can help...

  1. with my crazy care plan!! I had a patient who was two days post op a TAH. The abnormality is that she had very low H/H levels when pre-op they were normal. Even after a transfusion of 3 units they still did not come up significantly. I know that this should red flag to some major NANDA but for some reason I am really having trouble matching the situation up to one. I can't find anything in the book that seems to be caused by low H&H other than anemia which just doesn't seem to fit. Any suggestions??? Time is of the essence! Thanks a million!
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  2. 5 Comments

  3. by   Nrs_angie
    Quote from momto2beauties
    with my crazy care plan!! I had a patient who was two days post op a TAH. The abnormality is that she had very low H/H levels when pre-op they were normal. Even after a transfusion of 3 units they still did not come up significantly. I know that this should red flag to some major NANDA but for some reason I am really having trouble matching the situation up to one. I can't find anything in the book that seems to be caused by low H&H other than anemia which just doesn't seem to fit. Any suggestions??? Time is of the essence! Thanks a million!
    Your best NANDA nursing diagnosis would be RISK FOR INJURY r/t unstable H&H levels or something to that effect
  4. by   Leda
    What was your patient's response to the low H & H/what did you assess? Did she exhibit signs of impaired tissue perfusion? (pallor, hypotensive, tachycardic, etc.), activity intolerance? (orthostatic, fatigued, etc.) risk for injury? (orthostatic, unstable ambulating independently, etc.) fluid volume deficit (decreased urine output, increased urine specific gravity, etc.) Your nursing diagnosis is the patient's response to illness, injury, life crises, etc. List your assessments, cluster them and perhaps you will more clearly see how the low H & H "fits" into the total picture. Try this approach and you may be able to identify which NADA Nursing Diagnosis/Diagoses fit your patient's unique situation.

    Good luck on the care plan.
  5. by   momto2beauties
    Thanks so much for being willing to help me. That is one diagnosis I had not considered. While continuing to look I also came across Ineffective Protection. What do you think about that one?
  6. by   momto2beauties
    Quote from Leda
    What was your patient's response to the low H & H/what did you assess? Did she exhibit signs of impaired tissue perfusion? (pallor, hypotensive, tachycardic, etc.), activity intolerance? (orthostatic, fatigued, etc.) risk for injury? (orthostatic, unstable ambulating independently, etc.) fluid volume deficit (decreased urine output, increased urine specific gravity, etc.) Your nursing diagnosis is the patient's response to illness, injury, life crises, etc. List your assessments, cluster them and perhaps you will more clearly see how the low H & H "fits" into the total picture. Try this approach and you may be able to identify which NADA Nursing Diagnosis/Diagoses fit your patient's unique situation.

    Good luck on the care plan.
    Unfortunately (for me, good for the patient) she really didn't exhibit any other s/s. Her vitals were completely normal,good energy level. Now that I think of it though.....she did have some abdominal bruising....could that be related?

    You'll have to excuse me, my baby boy has been sick for a week so I'm working on little to no sleep.
  7. by   Nrs_angie
    Quote from momto2beauties
    Thanks so much for being willing to help me. That is one diagnosis I had not considered. While continuing to look I also came across Ineffective Protection. What do you think about that one?
    ok yes that will work,,, and also 'DELAYED SURGICAL RECOVERY R/T DECREASED OXYGEN SUPPLY TO THE BODY, AND INCREASED CARDIAC WORKLOAD.

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