the next time you are in clinicals ask your instructor for permission to go to medical records to look at the patient's chart. the people in medical records can pull her chart as long as you have the patient's name and the days she was an inpatient. they may specifically be able to access the labwork for you without pulling the whole chart.
ineffective protection rt anticoagulant therapy for dvt
this is constructed incorrectly. you need to be using a nursing diagnosis reference when putting a diagnostic statement together. it will give you the definition, related factors (etiology, or cause, of the problem) and defining characteristics (symptoms of the problem) of each of the nanda approved diagnoses. this information is also included in the appendix of taber's cyclopedic medical dictionary.impaired tissue perfusion rt venous insuff aeb redness, warmth and weak right lower ext.
you cannot use a medical diagnosis such as "dvt" in your nursing diagnostic statement as you have done. and, anticoagulant therapy is an incorrect etiology for this diagnosis. the definition of this diagnosis is decrease in the ability to guard self from internal or external threats such as illness or injury. anticoagulant therapy is a treatment and fails to meet the definition of this diagnostic problem because anticoagulant therapy has nothing to do with the body guarding itself from a threat. the threat to the body is the result of the anticoagulation therapy: elevated clotting factors. i see the choices for using this diagnosis as ineffective protection r/t elevated clotting factors or ineffective protection r/t abnormal blood profile secondary to coumadin therapy
i would diagnose this as risk for injury r/t altered clotting factors.
when using the diagnosis of impaired tissue perfusion
the body system involved must be specified. in this case, it is the lower extremities and the older diagnostic taxonomy advised us to add the wording "peripheral
" to the diagnosis. the updated taxonomy as of 2008 has split this into its own diagnosis: ineffective peripheral tissue perfusion.
anyone reading that diagnostic statement knows exactly what you are referring to.
, or related factor, is always
the cause of the problem (in this case, the ineffective peripheral tissue perfusion
). venous insufficiency
is a medical diagnosis and we can't use it as you have in a nursing diagnostic statement. do you know what it is? it is failure of the valves of the veins to work which impedes venous blood return to the heart.
the reason for this ineffective peripheral tissue perfusion
is what results in a decrease in blood circulation to the periphery that may compromise health
which is the definition of this diagnosis (page 141, nanda international nursing diagnoses: definitions and classifications 2009-2011
). your rt must
explain in as few words as possible how the decrease in blood circulation
has happened to create the perfusion problem from nursing's viewpoint. venous insufficiency
is the doctor's point of view of the situation. our nursing point of view is that there is "leg vein valve failure" (try saying that fast three times!) these are the related factors that the nanda taxonomy has provided that we can choose from for this new diagnosis and although venous insufficiency
isn't on the list it could be added (note: using a deficient knowledge etiology means having teaching interventions; if you use "deficient knowledge of leg vein valve failure" as an etiology be sure you know what its signs and symptoms are because your nursing interventions will include teaching the patient to monitor for them):
- deficient knowledge of aggravating factors (e.g., smoking, sedentary lifestyle, trauma, obesity, salt intake, immobility)
- deficient knowledge of disease process (e.g., diabetes, hyperlipidemia)
- diabetes mellitus
- sedentary lifestyle
if you want to stick with impaired tissue perfusion, peripheral
, you can see the list of related factors for this older diagnosis on these webpages:
the related factor for that diagnosis wants you to explain how oxygen is not able to reach the capillary level of the tissues.