I have to complete a concept map on this patient I had this past weekend. The good thing was that she was basically in great shape other than what she was admitted for and it makes it a little hard to come up with my diagnoses. Here is the pt info:
78 y/o female who is totally independent (own bath, ambulation with no assistance, no fall risk, 15 GCS)
Her admitting diagnosis was GI Bleed and anemia. She had noticed about 4 days prior to admission that she was getting very tired, weak, and fatigued. Also noted that her stools were black and tarry (GI Bleed). She had an endoscopy procedure which showed she had hiatal hernia with lesions which were causing the tarry stool. She was treated with Protonix (antiulcer agent) and now will be on lifelong Protonix at home. They already knew about the hiatal hernia so that is not a new finding. She said she developed the hiatal hernia and since it went undiagnosed for so many years she now has some HTN and Stage II Kidney Disease (both of which are well controlled). No smoking, no drinking. Lives with very nice spouse and talks of great relationships. Retired and comfortable. Nothing unusual on her assessments.
The only labs she had drawn were: PT: 13.1, INR 1.2 (she is on coumadin therapy for a fib and HTN), HGB 7.9, HCT 24.0 on 10-28-11 and HGB 10.7 and HCT 32.6 on 10-29-11.
Her VS during my shift were: BP 106/64 and 99/62, Temp 36.8, 02 sat 95% on room air, RR 20, 62 HR. She had absolutely no pain during and experienced no fatigue, etc during the shift. She had good understanding of everything that was going on and understood all her meds so she is very humble and compliant.
She was discharged at the end of my clinical day because they were comfortable with her HGB and HCT levels.
I just don't see too much going on with her so I'm a little if'y about what to do my concept map on.
I need at least 2 diagnoses. The diagnosis I came up with prior to meeting the patient was Risk for Injury r/t abnormal blood panel.
Nov 2, '11
I think the diagnosis "Risk for injury r/t abnormal blood panel" could use some work. What about her blood panel was a direct threat to her safety? Consider listing her symptoms that are due to her anemia instead of her lab values. Low HGB does not make one fall, the dizziness does. I know what you mean but care plans
and concept maps have a nitpicky way about them.
Fluid volume deficit also works well with any sort of bleed.
Also, does she have any psychosocial needs? If you are stumped on the physiological side of things, consider things like teaching needs, family dysfunction, emotional upset etc. It does not seem like she had issues like that but I just wanted to throw it out there.
Nov 2, '11
Well she has NO symptoms from anemia. No fatigue, tiredness, dizziness, nothing. No s/s of fluid volume deficit. She only had that upon her admission but I have to do everything based off MY assessment while she was in my care. That makes it difficult for me because she didn't have anything that jumped out to me.
No psychosocial either.
Nov 2, '11
If you have a nursing med/surg book that is published by Elseiver, the publisher offers help on the book's websitek. They offer a blank template, and you just fill in info. The site puts the info you have input into a concept map form. I don't know if other nursing publishers offer this service on their corresponding nursing book website.
Nov 3, '11
if she's still in the hospital her activity level probably isn't what she's used to at home. for example, i'll bet she's not climbing stairs to her bedroom, showering, cooking, shopping, or taking out the garbage. i'll bet that if her h&h are not much better than when she came in, she's probably still weak (activity intolerance? self-care deficit?) but you just aren't seeing it. this has implications for when she goes home, too-- will she really be ready to go back to her regular activity level? how would you know? (hint: "potential for ...")
her hiatal hernia may be old news, but certainly the bleeding lesions in it aren't.
i agree that "...due to lab results" is not a useful descriptive cause of a problem. which lab result indicates the cause? something like "activity intolerance due to (because she has) low tissue oxygenation related to (caused by) low hemoglobin/hematocrit" makes the connection and closes that circle. does that make sense?
this is why you take physiology and anatomy before you start learning responsibility for assessment and decision-making. good start.
as for psychosocial-- how do you know how she feels about all this? if i were being admitted at 78 for a gi bleed, unable to care for myself at home because i was weak and dizzy, i'd be scared. i'd be worried about whether it would happen again, if i might fall and no one would know, if i'd ever be able to go out or drive, if i'd end up in a nursing home or ever get out, who would feed the cat... people don't need to be actively weeping and distraught. the most challenging problems often are well-hidden.
Nov 3, '11
Another possible approach would be to start with a concept map of her "normal, healthy" needs as an elderly woman living independently. Even normal healthy people have health care and safety maintenance needs. Then add/alter the map based on the health problems she has been experiencing recently and the things she will need to do once she gets home as a result.
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