I have a careplan due Monday, and I am desperate for help!! I have to have an actual nursing diagnosis and a potential diagnosis. My potential is no problem. I am going with "Risk for injury related to anticoagulant use." My actual, on the other hand, is causing me quite a bit of difficulty. I need some advise. My pt was admitted with abdominal pain et subsequently diagnosed with a superior mesenteric vein thrombosis et a portal vein thrombosis. By the time I saw her (a few days later) her pain was a zero. That knocks out pain as a diagnosis. My next instinct was to go with Ineffective Gastrointestinal Tissue Perfusion, but she didn't seem to really meet the criteria for that diagnosis either. I will list her main problems: she had to be transfused with 2 units PRBCs due to anemia; she is on anticoagulant therapy; rates pain at zero; history of ASHD, HTN, stable angina, anemia, hemoccult positive stool, seizure disorder, et chronic ASA use at home. Her past surgical history is unclear, although she apparently had a hysterectomy sometime between 18-30 years ago. She mumbles when she speaks, and then she will speak clear at other times. (78 y.o. female). She is a very poor historian. Vital signs stable. Does have generalized weakness. Voids without difficulty. Bowels sounds normal X 4 quads. No hx of diarrhea/constipation prior to admit, however, some mild diarrhea since admit.
