1. 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!!!!
  2. 3 Comments

  3. by   lkwashington
    Was a BNP done since the patient has a history of CHF? GI bleed is a medical diagnose, you can not use it your NANDA. You have to reword it. AEB hypotension use what you observe. What is exactly the patient blood pressure? You are on the right track.
    Last edit by lkwashington on Nov 14, '10
  4. by   Sftblgrl21
    I'm not sure about the BNP? I only wrote down all of the abnormal lab values! Her blood pressures were very low (like 104/50?) she was taking a medicine that improved the blood pressure but I can't remember the name of it?
  5. by   lkwashington
    For an example: Risk for Constipation r/t pain medication AEB patient states "not having a BM in several days"