I had a patient who had a recent surgery for a craniotomy of an acoustic neuroma from the brain. She has a history of CHF, Osteoarthritis, hypothyroidism. Currently diagnosed with GI bleed, transient hypotension, hematuria, yeast infection and rectal lesion. Colonoscopy was performed due to patient having persistent hematochezia. 2-3 polyps were found but they didn't perform polypectomy because it appeared the patient had rectal carcinoma. Also, a severe case of cytomegalovirus was found. She went to surgery later that afternoon for a ventriculoperitoneal shunt. The following labs are low: sodium at 134, CO2 at 19, Calcium at 7, HgB at 11.2, HcT at 32.5, PLT at 115 and RDW was high at 17.7
I am definitely going to use Deficient Fluid Volume r/t gi bleed aeb hypotension
Thought about using Risk for Impaired Skin Integrity r/t (bed rest, frequent incontinence,hypovlemia leading to skin ischemia) aeb multiple lesions on behind (will need to get appropriate word?)
BUT I need another diagnosis? She is confused quite a bit of the time. I don't feel as though she understands too much more than direct commands. Possibly a deficient knowledge?
ANY HELP at this point would be AWESOME!!!!