Desperate for careplan help!!!! - page 2

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... Read More

  1. by   malenurse1
    This one is kind of a shot in the dark as coming up Nursing Dx's is not my strong point, but how about Ineffective peripheral tissue perfusion r/t compromised blood flow secondary to ASHD. This is a good learning expirience for me, thanks.

    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.
  2. by   twarlik
    Quote from francine79
    Speaking of nursing dx, I have a question. It seems lately that I have been seeing all these nursing dx that I have never heard before, on the board and in school, and I go to look them up, (I have the most recent list of NANDA approved dx) and they are not there. I have even had my instructor tell me to use the Risk for paralytic ileus dx, but it's not nanda approved. Are you able to just make up your own nsg. dx? Or are these old ones that are just no longer used anymore?
    I think it depends on the instructor. For my med-surg class we had to use NANDA approved dx. In mental health we could make up our own dx.
  3. by   RNMedic1977
    Here are some things to think about.......
    How about for the anemia (and since the pt received 2 units of PRBC's)
    Altered Cardiopulmonary Tissue Perfusion r/t anemia (blood loss) this pt is at risk for hypovolemic shock (if bleeding continues)
    How does the blood loss (Fluid Status) affect this pt's renal status (not to mention the HTN).....and don't forget to assess the Cardiac Output, Increased or Decreased?
    Hope this helps
  4. by   Wheaties
    is potential and possible almost similar?
    Last edit by Wheaties on Apr 6, '04

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