Desperate for careplan help!!!!

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    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.

    Any suggestions would be greatly appreciated.

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  2. 16 Comments...

  3. 0
    My suggestion would include Fluid Volume Deficit for both the diarrhea and the fact that her hemoccult was positive, indicating some bleeding in the GI tract. That's all that I can think of for now. Good luck!

    --icesk8ie
  4. 0
    Quote from rachhump
    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.

    Any suggestions would be greatly appreciated.
    I'm newer at the nursing diagnosis thing but let me give it a try:

    How about: FATIGUE r/t decreased oxygen supply to the body, increased cardia workload.
    You said she is a very poor historian? How about:
    Impaired MEMORY r/t anemia
    or for her weakness:
    Risk for FALLS r/t weakness

    I'd like to see what more experienced nursing students might choose. Maybe they can explain why they wouldn't choose any of the ones I chose? This is a great learning lesson for me also! Thanks for the practice!:stone
  5. 0
    Quote from icesk8ie
    My suggestion would include Fluid Volume Deficit for both the diarrhea and the fact that her hemoccult was positive, indicating some bleeding in the GI tract. That's all that I can think of for now. Good luck!

    --icesk8ie
    made a mistake - sorry
    Last edit by JENRN2BMICHIGAN on Apr 3, '04 : Reason: mistake
  6. 0
    Look at the decreased vascular perfussion-d/t cardiovascular disease
    or her angina d/t anemia (poor oxygenation) and d/t hypertension. Also a high risk for bleed d/t history of and use of asa.


    Quote from rachhump
    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.

    Any suggestions would be greatly appreciated.
  7. 0
    Okay, here's the thing- she had no diarrhea the day I saw her. I already did a careplan on fluid/vol def. this semester, so they won't let me repeat. Plus, not only do I have to do an actual et a potential (risk for) this time, but I have to have a short term goal et a long term goal for each diagnosis. I'm stumped. I started to go with knowledge def, but the criteria talks about return demo, etc. She didn't have anything to return demo.
  8. 0
    'knowledge def, but the criteria talks about return demo, etc. she didn't have anything to return demo."

    can she demonstrate through verbalization, if so, you can use knowledge deficit on any one of her diagnoses. imparied mobility r/t is a good one also as previously mentioned in a post.
  9. 0
    I have a problem with your potential diagnosis of "risk of injury R/T anticoagulant therapy" I was always taught that the diagnosis had to be something the nurse could action and you cannot action the anticoagulant therapy BUT you can make sure that they have the correct knowledge of how and why they are using the anticoagulants. You can minimise the adverse outcomes of the therapy. You can make sure you have maximised thier motivation to comply with the anticoagulant regime (especially if being discharged on warfarin).

    Now for the mesenteric vien thrombosis - ANY time you have disruption to the blood supply to the gut you risk sepsis - look it up.

    What is her absorption of food like??? Are we at risk of paralytic ileus???

    She has blood in her stool - there is one diagnosis right there along with potential for bleeding. Is the anaemia a chronic problem or is it related to bleeding from the GIT??

    You are tranfusing an IHD patient - what is her Ejection fraction? - is she at risk of pulmonary oedema/overload??
  10. 0
    Thanks for your input everyone. Gwenith, I especially appreciate the point you made about my "risk for injury" diagnosis. I had never been taught what you said, but it makes total sense to me. Risk for infection seems more appropriate in this case with the supporting clinical data I have. I was, however, curious what you use for your nursing diagnosis reference. Do you have a recent NANDA list? The most recent I have is from like 2001.
  11. 0
    I don't - I just used to teach it - many years ago. There are some good websites listed over in the student nuses forum though click on that forum they are in a "sticky" thread at the "top" of the forum.


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