Well, I guess it's my turn (again) to ask for help in here. I've been assigned my first concept map for my patient from my med surg clinicals. I need 4 nursing diagnoses, in order of priority. I think the prioritizing is the hardest part of all of this.
I kind of just wanted to put my thoughts out there to see if I'm on the right track. I remember from reading countless other posts on here that I should not be trying to fit my patient into a diagnosis, but rather look at my patient, figure out what I see and that should lead me to a diagnosis. Correct? So, I'm going to try to do that but I'm pretty new at this. Any pointers/gentle nudges (or not so gentle) would be welcomed!
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My assigned patient is a 71 yo male, admitted due to GI bleed. AO x 3, BP 96/56, HR 70, RR 16, T 98, PO2 98% room air. He denies being in pain.
His radial and pedal pulses are weak and irregular, and dysrhythmia can be heard on auscultation of atrial pulse (we haven't learned cardiac yet in med surg so I can't say specifics, ie S1, S2 yet). He is on cardiac monitoring and a call to telemetry confirmed he is in afib. His BNP is elevated, other cardiac markers in normal range. He takes both Lovenox and Coumadin at home, though since he has been in the hospital he has stopped taking these. Multiple bruises on his lower calves as well as some pitting edema (R=+1, L=+3). His PT/INR and aPTT are within range.
He is anemic. His Hgb, Hct, and RBCs are all low, in spite of receiving two units of PRBCs yesterday. He takes iron supplements and has a miralax prescription to prevent constipation. His last bowel movement was two days ago. He is asymptomatic for anemia. His skin is pink warm and dry. He moves with a steady gait, denies dizziness or shortness of breath, and his O2 sats have been consistently >95% on room air. Capillary refill
He has normal bowel sounds in all four quadrants. His first occult blood test upon admission was positive, a retest on the floor today came back negative.
He has elevated neutrophils and decreased lymphocytes.
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So based on all of this, I feel like there's a lot going on and a lot of nursing diagnoses to choose from. However, based on highest priorities, I want to look at ABCs first and what catches my attention most is his heart/blood. He has a slightly depressed BP, and inadequate RBCs, and he's in afib. Obviously his heart isn't functioning the way it should and probably not supplying adequate perfusion, so I think one of his priority nursing diagnoses should be Decreased Cardiac Output r/t atrial fibrillation and coronary artery disease AEB decreased blood pressure.
Still focusing on ABCs, his anemia and lowered RBCs would also put him at risk for inadequate oxygenation due to low RBCs, and bleeding due to his Hgb count and his use of coumadin and lovenox. His O2 sats have been fine so far, but he is at risk of inadequate oxygenation because of his decreased O2-carrying capacity... so I would add Risk for impaired gas exchange r/t anemia, and also risk for inadequate perfusion r/t anemia.
Finally, his last occult blood test was negative and they think his GI tract bleed cleared up on its own, but they aren't sure. I think any bleeding, especially with his risk factors, is pretty serious for him so I would put Risk for Bleeding r/t anticoagulants and history of GI bleeds.
