Care Plan Help!!

  1. 0
    My nursing diagnosis is risk for bleeding r/t anticoagulant therapy induced thrombocytopenia. Goal- Patient will remain free from bleeding.
    I had 2 outcomes that i thought were good, but my instructor says they are the same thing.
    1. Patient will remain free from bleeding injuries
    2. Pt. will explain methods to prevent bleeding injuries.
    I can only use one of these. I am stuck and can't think of any other outcomes. I have to submit this tonight. Any input from all of you smart people would be greatly appreciated!!!

    Thanks Much!!
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  4. 7 Comments so far...

  5. 0
    How about something measureble, but realistic for your goal?
    Like: Pt's platelet count will be between xxx and xxx within 48 hours (or what ever time frame seems reasonable. Also, keep your count reasonable--if he was very low, he is not going to bring it back to WLN in 48 hrs.)
    My instructor is big on measurable goals, then one of your outcomes can be whether it was met or not.
    Hope this helps! Good luck!
  6. 0
    Thanks, my instructors are also huge on measurable outcomes. Only problem is, I do not have access to the chart anymore and I did not record the PLT count for this patient.
  7. 1
    Hummm...do you have a PT/INR? if you don't you should still be able to use it since it goes along with his risk for bleeding and anticoags. Goal would be maintain PT/INR within xxx and xxx, (or whatever changes are need) For outcome, you could put no s/s of bleeding and list any additional PT/INR results done. If he didn't have another one done by your last clinical day, I would list that in so your instructor knew you were looking for it....Just a thought
    Last edit by GaNurse1969 on Feb 9, '09 : Reason: spelling error
    nursem007 likes this.
  8. 0
    The diagnosis of Risk for Bleeding R/T anticoagulant therapy induced thrombocytopenia isn't an official NANDA diagnosis. I understand, however, that some nursing programs want students to formulate diagnoses in their own words. The NANDA diagnosis for this would be: Risk for Injury R/T abnormal clotting factors. The outcome of an anticipated problem is always that the risk (in your patient's case, bleeding) doesn't manifest. So, what specific bleeding problem are you trying to prevent from happening? Can you put a name to it? (frank hemorrhage from a wound or incision, hematoma, ecchymosis, petechiae, hemoptysis, hematuria, etc.) That is your final outcome. The nursing interventions must be:
    • strategies to prevent the problem from happening in the first place
    • monitoring for the specific signs and symptoms of this problem
    • reporting any symptoms that do occur to the doctor or other concerned professional
    Outcome: By ___ patient will have no bleeding as evidenced by ___.
  9. 0
    Quote from Daytonite
    The diagnosis of Risk for Bleeding R/T anticoagulant therapy induced thrombocytopenia isn't an official NANDA diagnosis.
    I thought the same thing Daytonite, but after checking the NANDA website, I found that I was mistaken and it is a new NANDX dx. I also noticed some "retired" dx's and some "revised" dx's. They can be viewed with the link below

    http://www.nanda.org/DiagnosisDevelo...ates/Risk.aspx

    NANDA-I Taxonomy Updates


    New Risk Diagnoses Diagnosis Label / Submitted By
    Risk for Bleeding
    Sheri Holmes, MSN, APRN BCRisk for Compromised Resilience
    Angela Oldenburg, BA, RN
    Shelly Eisbach, PhDc, MSN, RN
    Melissa Lehan-Mackin, RN, BSNRisk for Decreased Cardiac Perfusion
    Jennifer Hafner, RN, BSN, PCCN, TNCCRisk for Disturbed Maternal / Fetal Dyad
    Sheri Holmes, MSN, APRN BCRisk for Dysfunctional Gastrointestinal Motility
    Joan Klehr, RNC, MPHRisk for Electrolyte Imbalance
    Jennifer Hafner, RN, BSN, PCCN, TNCC
    Leah Mylrea Speltz BSN RNC ACCE STABLE ACLS NNR
    Kathy Weaver, RNRisk for Ineffective Cerebral Tissue Perfusion
    Jennifer Hafner, RN, BSN, PCCN, TNCCRisk for Ineffective Gastrointestinal Tissue Perfusion
    Jennifer Hafner, RN, BSN, PCCN, TNCCRisk for Ineffective Renal Perfusion
    Jennifer Hafner, RN, BSN, PCCN, TNCCRisk for Shock
    Jennifer Hafner, RN, BSN, PCCN, TNCCRisk for Vascular Trauma
    Cristina Arreguy-Sena, PhD, RN
    Emilia Campos de Carvalho, Nurse, Master, PhD
    Last edit by CT Pixie on Feb 9, '09
  10. 0
    Quote from CT Pixie
    I thought the same thing Daytonite, but after checking the NANDA website, I found that I was mistaken and it is a new NANDX dx. I also noticed some "retired" dx's and some "revised" dx's. They can be viewed with the link below

    http://www.nanda.org/DiagnosisDevelo...ates/Risk.aspx

    NANDA-I Taxonomy Updates


    New Risk Diagnoses Diagnosis Label / Submitted By
    Risk for Bleeding
    Sheri Holmes, MSN, APRN BCRisk for Compromised Resilience
    Angela Oldenburg, BA, RN
    Shelly Eisbach, PhDc, MSN, RN
    Melissa Lehan-Mackin, RN, BSNRisk for Decreased Cardiac Perfusion
    Jennifer Hafner, RN, BSN, PCCN, TNCCRisk for Disturbed Maternal / Fetal Dyad
    Sheri Holmes, MSN, APRN BCRisk for Dysfunctional Gastrointestinal Motility
    Joan Klehr, RNC, MPHRisk for Electrolyte Imbalance
    Jennifer Hafner, RN, BSN, PCCN, TNCC
    Leah Mylrea Speltz BSN RNC ACCE STABLE ACLS NNR
    Kathy Weaver, RNRisk for Ineffective Cerebral Tissue Perfusion
    Jennifer Hafner, RN, BSN, PCCN, TNCCRisk for Ineffective Gastrointestinal Tissue Perfusion
    Jennifer Hafner, RN, BSN, PCCN, TNCCRisk for Ineffective Renal Perfusion
    Jennifer Hafner, RN, BSN, PCCN, TNCCRisk for Shock
    Jennifer Hafner, RN, BSN, PCCN, TNCCRisk for Vascular Trauma
    Cristina Arreguy-Sena, PhD, RN
    Emilia Campos de Carvalho, Nurse, Master, PhD
    God! I hate the new copy of Nursing Diagnoses Definitions and Classificstion 2009-2011. It's organized differently and I can't find anything in it as efficiently. You're right, it's there. I don't have any specific information on its use. I understand that students need to do what they need to do for a grade.
  11. 1
    Thank you to all who responded. I feel a sense of relief! I love this website!!
    mguido6 likes this.


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