Problem # 1: Alteration in nutrition, less than body requirements related to decreased appetite as evidenced by nausea and vomiting.
Goal: Patient will maintain current body weight +/- 3 lbs over the course of her hosptial stay.
1. Weigh on admission and then weigh daily.
2. RD Consult for Diet and Nutrition Counseling
3. Monitor Food and Fluid Intake
4. Keep MD Informed of any weight loss
Problem # 2: Increased risk for alteration in tissue perfusion related to decreased cardiac output as evidenced by bradycardia.
Goal: Patient's heart rate will remain in normal range.
1. Telemetry monitoring
2. Vitals signs in accordance with facility policy.
3. Monitor labs as ordered for potassium and mag. levels
4. Keep MD involved and informed with changes to rate and rhythm
Problem # 3: Bleeding as evidenced by positive hemooccult test
Goal: Patient will be free from bleeding
1. Test all stools for occult blood
2. Monitor lab values (i.e. H&H and RBC)
3. Encourage patient's nutritional intake.
4. Keep MD Informed of changes to labs or for s/s of increased bleeding
When you do the work-up on your patient, look at the patient's overall global view. She is going to lose weight is she does not eat. That places her at increased risk for weight loss. In addition, her bradycardia is going to impact upon her ability to perform self care. She may fatigue with ease related to SOB from her decreased cardiac output. This is another approach rather than using the problem that I stated. Use your Nursing Diagnosis book
to help you find the right ones to use. Coming to this board is a good idea as many of the nurses here have been through this before too. Good luck and I hope these help.