Another nursing care plan question

[momto2lilgirls]

I have been reading over countless threads relating to help with nursing care plans and was reluctant to ask for help, but I decided to do it anyway.

I am a 1st semester PN student working on my second care plan. Not much was expected of us on our first, so (sufficeth to say, I didn't go whole hog while working on it). This time however, I am having much more difficulty preparing a legitimate, properly-structured (NANDA) nursing diagnosis. In my PN program, we aren't allowed to perform assessments on the patients we pick for our care plans. We are only allowed to gather objective information about their medical conditions from their medical chart.

This, as you well know, makes it almost impossible to create a legitimate care plan because most of the stuff is being "invented" or "made up". I chose a patient with:

long history of RA with resultant chronic neutropenia and thrombocytopenia

right heel and right hip cellulitis (with MRSA-infected wounds)

hypertension

hyperlipidemia

GERD

and most recent chief complaint (why she is in nursing home) is right occipital CVA with resultant left eye blindness

I have passed her meds a few times, so I know a little about her, and one of the reasons I picked her was because she had so many interesting things wrong with her, I thought it was be easy to create a solid care plan.

Here is a visual:

She has wound vacs to both R heel/hip

She is on neutropenic precautions (PPE)

PICC line to RUE

She ambulates and transfers with assistance

Fall risk score is 7

Braden score for skin integrity is 19

Vancomycin trough 22.2 (I have no idea what this means, but the range was 8.0-20.0)

and ALL of her labs WBC, RBC, Hgb, Hematocrit, platelets, ANC, cholesterol were all WAY out of range as you would suspect (I don't have the exact numbers in front of me...sorry)

The only meds she is on what were not prn were:

vancomycin 750 mg IV q 48 hr

simvastatin po q HS

coumadin 25 mg po q day

ASA 325 mg po q day

Pepcid 20 mg po q day

prednisone 20 mg po q day

losartan 50 mg po q day

and I think there is a opiate analgesic order but only prn

related to her CVA, she doesn't have any -plegia, -phasia, or other typical s/s except the L eye blindness and I have no idea where the RLE wounds came from

so, I thought I was being smart by picking her, but what I am finding is difficulty in choosing appropriate nursing diagnoses (I only need 2) because we were told to pick them based on one of her medical diagnoses. So...unfortunately I only have signs and no symptoms (except pain, I have heard her verbalize pain previously)

I will use chronic pain as my first ND, but what for the second? I dont think I can use risk for infection (even though she is neutropenic) because she is already on vanco for the MRSA in her RLE.

I thought of using impaired skin integrity because of the wounds but I don't know if they are a result of immunological deficit, immobility, or other mechanical factors. Not being able to visualize the wounds kind of makes that one difficult, I think.

I also though of risk for injury, but do I tie the r/t to her RA (immume-autoimmune dysfunction), abnormal blood profile (neutropenia, thrombocytopenia, etc), or maybe I should tie it to something related to her resultant L eye blindness. I can't use risk for falls....I already wrote my first care plan on that one.

There are probably so many more obvious things maybe related to her MRSA or the CVA care, but I do not know enough about nursing yet to create a care plan from scratch without the symptoms from an assessment. It is crazy to have a first semester nursing student (a PN student no less) write a care plan "blind."

I appreciate any help I can get. Thank you so much!!

[Daytonite, BSN, RN]

• Chronic Pain R/T inflammation of joints secondary to RA [S/S: your pain assessment]
  
• Ineffective Protection R/T neutropenia and thrombocytopenia secondary to anticoagulation therapy [S/S: altered clotting factors, the S/S of her infection and impaired healing of the right heel and right hip cellulitis]
  
• Disturbed Sensory Perception, Visual R/T altered sensory reception [s/S: blind]
  

With your next patient, talk with them and ask questions. Ask about their medical history and what they have had done. Ask why the doctor ordered the medications they are getting, why they are in the hospital, what the doctor plans to do for them. That subjective data is still good to use for care plans if that is all you have available.

[momto2lilgirls]

Wow, thanks for the speedy response.

Why is it Ineffective Protection instead of Risk for Bleeding? My instructor recently sent us an email with new 2009-2011 nursing diagnoses organized according to a nursing focus by Doenges/Moorhouse Diagnostic Divisions and under "Circulation" it says Risk for Bleeding. Is this somehow a different diagnosis?

Thanks!

[Daytonite, BSN, RN]

You can use Risk for Bleeding if you want, but that only covers a potential problem. Ineffective Protection R/T neutropenia and thrombocytopenia secondary to anticoagulation therapy [S/S: altered clotting factors, the S/S of her infection and impaired healing of the right heel and right hip cellulitis] covers the risk for bleeding as well as her low WBC count that has given her delayed healing with the ulcers and allows you to also address any signs and symptoms of infection that she has. Its kind of an all purpose diagnosis that is covering several problems that have occurred secondary to treatments she is getting.

[momto2lilgirls]

Oh, I see. Like, Ineffective "Protection" as in immune system or defense mechanisms? Thanks for the explanation! I have seen how many people you have helped on here and really appreciate your time.

[Daytonite, BSN, RN]

Something else that came to mind was that I got the impression that you wanted to create a nice care plan. When using a diagnosis like Risk for Bleeding you are restricted in your nursing interventions. They can only prevent the problem (bleeding, or hemorrhage) from happening, you may monitor for signs and symptoms of bleeding and you can report signs or symptoms of bleeding to the appropriate person and that is all you can do. Your goal is to prevent the patient from bleeding.

With Ineffective Protection you have an actual problem(s) to sink your teeth into and develop nursing interventions that involve some hands on nursing care. I was thinking that this would be more what you were looking to do with a care plan.

[momto2lilgirls]

that was my goal... thanks..

i used ineffective protection... here are the nursing interventions i am considering using:

NI #1 -- follow contact precautions including handwashing/use of PPE when providing patient care

Rationale -- infection control procedures prevent the transmission of pathogens

Pt response (we are not required to make goal statments) -- cross-contamination does not occur to other pts

NI #2 -- perform regular skin/wound assessments

Rationale -- monitor wound healing or signs of worsening infection

Pt response -- RLE shows signs of healing or shows no signs of worsening

NI #3 -- educate patient on s/s of generalized and local infection, e.g., fever, pain, erythema, edema, exudates

Rationale -- prepares patient to manage health-related issues at discharge AND involves pt in her plan of care

Pt response -- pt verbalizes s/s of infection to monitor for

NI #4 -- teach patient effectiveness of well-balanced and healthy diet/exercise using the new MyPyramid.gov

Rationale -- maintains or improves general health condition/mental well-being

Pt response -- pt makes proper, nutritious food choices including effective protein sources (Ensure, etc.)

NI #5 -- teach patient how to use PPE for neutropenic precautions

Rationale -- patient safety by infection control (?)

Pt response -- pt wears appropriate PPE (mask, gloves) when outside isolation room

I am not sure what else is expected of us as PN students working with LTC residents. I thought this was pretty good.

[Daytonite, BSN, RN]

The patient also has thrombocytopenia because they are on Coumadin. She needs to be protected from skin injuries (bumps, bruises, cuts), so make sure she has geriarms and legs on (or protective coverings on her arms and legs), a soft toothbrush needs to be used when brushing teeth, no forceful blowing of the nose, no needlesticks unless absolutely becessary and then pressure needs to be held over the puncture site for several minutes until bleeding stops and no straining at any activities. Monitor for signs and symptoms of infection (Temperature > 38° C or 90 beats/min, Respiratory rate > 20 breaths/min or Paco2 12,000 cells/μL or 10% immature form).

[momto2lilgirls]

I am glad you pointed that out.

They take her PT/INR twice a week, is that more than necessary? I have done it once myself and never really paid much attention to applying pressure to the fingerstick long enough to make sure it stopped bleeding for certain, but that may have been before I saw her chart.

Also, why is she on coumadin AND aspirin? isn't that sort of dangerous? I will ask my instructor this question and she will say "don't worry about it, you do not need to know that at this time" However, if I am doing a patient's PT/INR that has thrombocytopenia, don't you think it's kind of important to know the answer to that question, even if it's not the answer I thought it was?

thanks for your help

[Daytonite, BSN, RN]

The PT/INR is being done because she is on Coumadin (warfarin) and if it is being done twice a week it is because they are trying to titrate and adjust her dose to get her anticoagulation into a therapeutic range. Look up the drug. She must have had a blood clot or is in danger of developing a blood clot and that is why she is on this drug. The reason should be stated somewhere in her chart. Thrombocytopenia is a side effect of long-term prednisone therapy, but I cannot state for a fact that her thrombocytopenia is because of her prednisone use.

[NurseKatie08, MSN]

Just an FYI: I wonder if the patient's Coumadin dose is actually 2.5 mg po daily? I've never seen anyone receive 25mg of Coumadin at once.

[UM Review RN, ASN, RN]

Just an FYI: I wonder if the patient's Coumadin dose is actually 2.5 mg po daily? I've never seen anyone receive 25mg of Coumadin at once.

Good eye, Katie! I've never seen a dose that high either.