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?
first of all, the priority sequence of the nursing diagnoses is not correct. a "risk for" diagnosis almost never is sequenced first because it is not an actual problem. actual problems are always sequenced before potential problems.
second, poor tissue perfusion is not an official nanda diagnosis and i have no idea what you mean by it. poor tissue perfusion of what tissues? the diagnosis of decreased cardiac output
covers the poor tissue perfusion of the heart. the edema is evidence of that.
third, if the patient is actively bleeding and hypovolemic then there is no risk for fluid volume deficit
. there is already deficient fluid volume
[decreased intravascular, interstitial, and/or intracellular fluid. this refers to dehydration, water loss alone without change in sodium.
(page 84, nanda international nursing diagnoses: definitions and classifications 2009-2011)] if the symptoms are there. the evidence (assessment information) you have of the deficient fluid volume
is the tachycardia, decreased urine output and hypotension. someone who has active gi bleeding would be pale and weak. when they try to get up they become diaphoretic and tachycardic and sometimes need help to get back to bed. they have low hemoglobin and hematocrit levels. if this patient had those symptoms then deficient fluid volume
would be the diagnosis to use. this would be sequenced after decreased cardiac output
please look at this thread for information on the construction of a care plan using the nursing process and how to determine diagnoses: http://allnurses.com/general-nursing...ns-286986.html
- help with care plans
Last edit by Daytonite on Feb 20, '10