Care plan help! IJ DVT

  1. 0
    hello all!

    i'm formulating the top two nursing diagnoses for my patient who came in with a dvt in her right internal jugular dialysis catheter. she was put on a heparin protocol and had the line pulled the day of my shift. i'm not very confident with care plans and was hoping for feedback. my priority diagnosis is:

    1. risk for ineffective tissue perfusion related to interruption of blood flow as evidenced by deep vein thrombosis to right internal jugular dialysis catheter.

    expected outcomes:
    client will demonstrate adequate tissue perfusion aeb blood pressure, pulse rate and rhythm within normal parameters for client; strong pulses, and ability to tolerate activity without dyspnea, syncope or chest pain.

    interventions
    follow anticoagulation therapy per heparin protocol. monitor lab levels for effectiveness.

    monitor vital signs. know patient baseline. report variations.

    monitor neuro status frequently- differentiation in baseline could be indicative of thrombosis dislodging.

    administer anti-hypertensive therapy as ordered to control blood pressure and prevent further complication of dvt.

    monitor for chest or neck pain, shortness of breath, diaphoresis, nausea and vomiting.

    monitor peripheral pulses. if there is a new onset of loss of pulses with bluish, purple or black areas and extreme pain, notify the physician immediately.

    continuous cardiac monitoring.
    ---------------------------------------------------------------------------------------------------------------
    does this sound right for a priority diagnosis- if not, any other ideas?
    any feedback or suggestions would be greatly appreciated!
    thank you & have a wonderful day!
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  3. 3 Comments so far...

  4. 1
    Quote from brittney
    hello all!

    i'm formulating the top two nursing diagnoses for my patient who came in with a dvt in her right internal jugular dialysis catheter. she was put on a heparin protocol and had the line pulled the day of my shift. i'm not very confident with care plans and was hoping for feedback. my priority diagnosis is:

    1. risk for ineffective tissue perfusion related to interruption of blood flow as evidenced by deep vein thrombosis to right internal jugular dialysis catheter

    thank you & have a wonderful day!
    welcome to an the largest online internet nursing community!

    we are happy to help with home work and although we don't do the work we will lead you to the right answers so you can develop your critical thinking skills.

    for a good care plan, let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first. you need to know the pathophysiology of your disease process. you need to assess your patient, collect data then find a diagnosis. let the patient data drive the diagnosis. what is your assessment?

    the medical diagnosis is the disease itself. it is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

    care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. it is trying to teach you how to think like a nurse. think of them as a recipe to caring for your patient. your plan of how you are going to care for them.

    from a very wise an contributor daytonite.......

    every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the nanda taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. you need to have access to these books when you are working on care plans. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

    don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics.

    here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:
    1. assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
    3. planning (write measurable goals/outcomes and nursing interventions)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met)

    a dear an contributor daytonite always had the best advice.......check out this link.
    http://allnurses.com/nursing-student...is-290260.html

    you need a good care plan book. i prefer gulanick: nursing care plans, 7th edition. they have an online care plan constructor. it used to be free but they caught on so now you need to buy the book to use the constructor.

    care plans must be chosen from the "approved" script....nanda. i think the biggest mistake students make is that the need to let what the patient says, does and feels (the assessment) dictate what you do next. not the medical diagnosis and try to fit the patient into diagnosis.

    what does the patient say? what are the labs? is the patient compliant with the dialysis? what does the patient need? what is the most important to them now? what may kill them first. your assessment gives you this information. what is the largest danger to the patient right now? is this a real patient? this is where i think students get so confused trying to assess their text books.......the driver for the care plan is the patient needs.

    this patient has many immediate need which one is first? well that would depend on lab works....if the potassium is critically outrageously high and they can't get dialysis because the catheter is clotted...that is a critical life threatening value. if this renal patient is i pulmonary edema from fluid over load and can't have dialysis...that is a life threatening priority. priority is based on the abc's first....what is going to kill them first and according to maslow's.....which is causing the most risk to the patients life

    look at maslow's to tell you which priority precedes the next.

    the greatest priority is at the bottom (the largest platform)and work your way up.

    so........let's look at your statement since you haven't provided any assessment data. "patient who came in with a dvt in her right internal jugular dialysis catheter. she was put on a heparin protocol and had the line pulled the day of my shift." the patient has a ......"dvt in her right internal jugular dialysis catheter" indication that the catheter was the only thing clotted......what exactly is the diagnosis. it would be unusual for a heparin drip to be started for a blocked/clotted vac in once the line was removed unless there was a thrombus noted in the jugular vein. how does the catheter alter circulation, tissue perfusion and blood flow when the catheter, and the clot, is removed? then ther emust be a clot in the vein itself? right?

    i know this sounds picky, but when you are dealing with a patients life it's missing the details that can kill someone. it's like trying to make bread without out any yeast......the bread is a failure because you forgot/missed something or you use salt in the brownies instead of sugar......i mean they are both white right? so details are a big deal the care plan is the recipe to teach you how to properly care for a patient and plan ahead if the unthinkable complication arises.

    i am going to assume (i hate assuming) that the patient has a clotted/thrombosed renal access catheter with evidence of the ij (internal jugular) clot/thrombus in the jugular vein.

    although the vascular catheter is in the vein, when the catheter is clotted it is not referred to as a dvt (deep vein thrombus) the clot is in the catheter not the vein. that is called a clotted/thrombosed vac (venous access catch). a "dvt" is their term used to describe a clot in deep veins. while more commonly in the legs. clots cam form any where in the body and pose a risk to the patient.

    what is dvt? what are the complications? what is important to look for that would be an emergent situation for this patient. what did your assessment show? is the patient getting enough o2. are they having chest pain?

    what is the largest risk/complication from a dvt? what would happen to your patient if a piece of this clot broke off and moved? how would this affect your patient? why is the location of this thrombus/clot of particular danger to this patient? would a piece of this clot breaking off and going to the heart/lungs/brain be a priority to this patient?

    what do you think?
    mickey_student likes this.
  5. 0
    Thank you for all of your time to reply. The patient's admitting diagnosis was IJ DVT. She was put on the Heparin protocol once it was found after admission in the ER (confirmed: (+) DVT to right IJ vein per arterial doppler ultrasound) and the physician later determined to have the line pulled. She had the line pulled ((during my shift of care) 3 days after being put on Heparin), not vice versa.The confirmation of the DVT seems to be the only piece of assessment data that is meaningful in her diagnosis- initially when she first presented to the ER, she of course reported pain and shortness of breath. During my shift she was stable.

    That being said, am I thinking along the right lines? If the anticoagulant therapy had been unsuccessful, isn't the main concern with the patient the risk that the clot could break off? Should I specify the diagnosis to risk for ineffective cerebral tissue perfusion? Are my interventions appropriate with perhaps the addition of neuro checks?
  6. 0
    right, your largest risk is pulmonary emboli. the clot is sitting right by the superior vena cava and right atrium. but the dvt is the medical diagnosis....what information did your assessment give you about the patient? the risk for complication/showering of embolus is present as long as the clot is there......it could take several days of continuous heparin therapy to "dissolve" the clot. your diagnosis still mentions the catheter which is no longer there ............... risk for ineffective tissue perfusion related to interruption of blood flow as evidenced by deep vein thrombosis to right internal jugular dialysis catheter.

    she has a thrombus in her jugular . there for that is not a risk for but is....

    ineffective tissue tissue perfusion r/t ij thrombus/clot aeb carotid doppler/ultrasound. your interventions are good.

    here are some ideas for potential nursing diagnostic statements that you could use:

    impaired comfort r/t impaired tissue perfusion from jugular thrombus aeb pt c/o pain.
    risk for impaired gas exchange r/t alteration in supply of oxygen or the inability to transport oxygen or changes in the alveolar-capillary membranes due to pulmonary emboli
    risk for ineffective breathing pattern r/t pulmonary emboli from jugular thrombus.
    risk of acute confusion r/t decreased supply of oxygen to the brain r/t showering of emboli from jugular thrombus.
    risk of acute bleeding r/t anticoagulant therapy aeb heparin drip.



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