I am working on my concept map/care plan for my critical care rotation.
My patient has a history of MI and Diabetes. On the day i cared for this patient they had an active GI Bleed and Afib. I established that i would make
1. Risk for Fluid Volume Deficit r/t
I chose this as my number 1 priority because on the day i cared for this pt. they were actively bleeding. I would have chosen Cardiac as my number one had this not been the case. Also, the albumin was 2.2 i wonder if there was third spacing exacerbating this due to being NPO for an extended period of time.
My evidence for this is
Poor pulses - +1
Edema - +2
Cap refil < 3 seconds
Decreased bowel sounds - possibly not enough blood flow reaching the gut?
Nausea - zofran on med list
Distention/pain - again possibly not enough bloow flow to gut?
This patients vital signs proved - Tachycardia, tachypnea, and hypotension.
Labs: CR high, no ABGS or BUN available. Albumin 2.2
Meds: Zofran, lasix, digoxin
Input: NPO 1000ml/day NS
Output: < 30ml/hr .... Bowel management system: Active GI bleeding.
2. Decreased Cardiac Ouput r/t decreased ventricular filling, altered afterload, impaired contractitlity, altered rate and rhythm, increased o2 demand, and cardiac disease.
3. Poor Tissue Perfusion r/t hypovolemia, myocardial ischemia, low hemoglobin, and reduced arterial blood flow.
This patient had visible PAD "cowboy boots", edema 2+ in lower extremities.
Do i seem to be headed in the right direction?