Quote from Lb6283
Help please! I have a concept map due tomorrow and I am stuck.
My pt. is a 79yr old Caucasian male. His admitting diagnosis was cellulitis, dependent edema, renal insufficiency, and chronic thrombocytopenia. Has a history of acute renal failure, anemia, disuse myopathy, gout, HTN, and hyperkalemia.
WBC 2.2 (normal range 4.8-10.8)
RBC 2.19 (4.7-6.1)
Platelet 33 (130-400)
Hgb 7.7 (12.6-17.4)
Hct 22.4 (37-57)
MCV 102 (80-94)
MCH 35 (27-31)
Vitals: T 97.1-99.7, HR 73-93, RR 18-20, O2 93-98, BP 117/54-126/72
Non-pitting edema, 1+ right foot. Pt. states that symptoms(pain) are made worse when standing. Redness and swelling present in both feet.
My pt. received 1bag of PRBCs and 2 units of platelets. He tolerated it well. VSS.
I don't know where to start or how to prioritize my nursing diagnosis'. So far I have:
-Risk for infection r/t inadequate secondary defenses to anemia.
-Risk for impaired skin integrity r/t inflammatory process damaging skin
-Ineffective tissue perfusion: peripheral r/t edema
Someone please help me get on the right track and to come up with some more nursing diagnosis'! I am stumped for some reason.
Risk for infection: what other lab test show a risk for infection (generally, RBCs and H&H aren't going to be the big ones)
Cellulitis- already has an infection- so what complications do you need to address?
- skin integrity already effected
What other issues can anemia cause?
Do you have the potassium level?
Pain is always important to address if there are diagnoses with probable pain
Risk of blood loss (thrombocytopenia)
Fluid imbalance - renal failure, edema
What issues are there with decreased mobility? (has myopathy from disuse)
THEN, what order do they need to be in - ABC, then Maslow's.....
See what you come up with