Published Nov 7, 2010
LysL
1 Post
I just worked with a patient and really need help determining the priority nursing diagnosis based on the following data...
All current medical dx: strep sepsis, DIC, aplastic anemia, thrombocytopenia, multi system organ failure, (possible leukemia - results not in yet)
Current s/s: bleeding from mouth, nose, all lines (PIV, A line, CVP, HD cath), petechiae over entire body, blood pooling, peripheral edema, low Hem, low Hct, really low WBC (0.4), low Plt, low Rbc, high creat, BP 88/43, T 97.5, HR 140's-150's, on an oscillator, age 3, weight 16.6kg, elevated PT/PTT, ascites in pelvis, enlarged liver. Patient is on dialysis too.
Can someone please help me figure out where to start with all of this?
I was thinking Ineffective Protection R/T inadequatly functioning immunse system AEB ??