Nursing concept map. Am I in the right ballpark?

[kvothe231]

Hello, I would really appreciate some help in deciding on a priority nursing diagnosis for my patient and understanding their lab values. This is the patient I had on their second day of admittance to the hospital:

The patient is 83 years-old. They came into the ER with shortness of breath and c/o frequent watery stools. Pt stated that she is anemic and has had dizzy spells for the past 2 years, but the incidence of the spells has increased in the last 2 weeks. Hx: GERD, SOB, HTN

Abnormal lab values on the day of admittance: RBC (1.7), Hgb (4.4), Hct (14.8), INR (1.06). As well as decreased MCHC (29.7) and elevated RDW (15.6). Sodium (132), chloride slightly elevated at (108) with chem panel Co2 low at 14. BUN (37) and creatinine (1.7) and GFR (29). Total protein (9.3), albumin (2.4), and globulin total (6.9) with Alb/Glob ratio at 0.3. Pt received 3 units of blood between these values and when I took care of them.

Vitals are Temp 97.4; BP 150/65; Pulse 61; Respirations 20; Sp02 98%. Abnormal assessment findings: heart murmur heard around left sternal border; chronic mild, non-pitting edema in the left ankle and foot w/ no complaints of pain (pt said she has had the issue for a long time); generally irritable and exhibited mild general weakness. All other systems were WDL. I & O, while I don't have the numbers on me, was reasonably balanced (within 200ml).

She was receiving endoscopy prep thus she received poor nutritional intake and was having liquid bowel movements.

Pt had an apparent GI bleed and was confirmed when I preformed an occult blood test.

So as to understanding the lab values... The pt obviously has a GI bleed which has led to the decreased levels of RBC, Hgb, Hct, etc. The frequent bowel movements over the last days leads me to believe that Co2 and Cl- are related to metabolic acidosis secondary to diarrhea/dehydration. The mild hyponatremia is caused by the diarrhea as well. The BUN, createnine, and GFR are indicative of kidney failure. I believe the total protein (9.3), albumin (2.4) and globulin (6.9), alb/glob ratio (.3) are also indicative of kidney disease.

As for a nursing diagnosis, although it seems like their (risk for) anemia is still at large with the active GI bleed, they didn't exhibit any signs of having respiratory distress or poor O2 sats.

I'm basically tossing around the following ideas:

Activity intolerance r/t general weakness aeb complaints of weakness upon moving to and from the bathroom

Diarrhea r/t bowel irritation secondary to GI bleed aeb multiple liquid bowel movements a day

Impaired nutrition: less than body requirements. I'm not positive about this one. She was on a clear liquid diet and then given Golytely for colon prep and malabsorption can be added due to frequent bowel movements. It sounds good in my head, I'm just not sure about aeb information. That is a little confusing for me.

My last thought would be related to the heart murmur. However, I'm not sure about diagnosing around that as I have little knowledge of the type of murmur, and the chart didn't say what kind. I am aware that it would be decreased cardiac output, but I find I'm not sure where to go with it.

I apologize for the long post but wanted to provide as much relevant information as possible. I would appreciate any effort put into pointing me in the right direction!

[smf0903]

While I am no super whiz at care plans/concept maps (just putting that out there! LOL), it appears to me that you are working in the opposite direction than you should be (assigning a diagnosis and trying to pull info to make it fit). Group your info first, that will lead you to the diagnoses. With the info you've given, there are a pluthera of diagnoses!

This may not have helped, but if you go back and group your info into your functional health patterns, it truly will help. Good luck! I'm sure someone else will be able to help a bit more :)