Care plan help! Patient with cirrhosis and thrombocytopenia

  1. 0
    Hi everyone! I need input.
    I had a patient this week with 3+ edema in bilateral lower extremities and ascities.
    She is throbocytopenic with hematuria and a bloody sputum with her cough. She has alcoholic cirrhosis, and her condition is not looking good. She signed a DNR 3 days ago.
    My ? is, would it be correct to say she has fluid volume deficit r/t bleeding even though she has edema and ascities? If not, what is a good diagnosis for someone who is actively bleeding? Thanks for your input!
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  3. 8 Comments so far...

  4. 0
    Decreased tissue perfusion, decreased cardiac output, impaired Gas exchange r/t inadequate amount of oxygen carrying capacity in blood.. Do you all use P.C.s? If so..PC:Hemorrhage. .PC:esophageal varices
  5. 0
    Bleeding would probably trump edema and ascites unless her breathing is affected > ineffective breathing pattern r/t pressure on diaphragm and reduced lung volume 2 ascites then of course oxygenation would be first.. fluid volume deficit and excess would be after I would say
  6. 1
    You get some sick patients......Think about it....it can actually be both. They can have extracellular overloaded and intravascular depletion....so someone can have edema and bleed to death.

    But don't pick you diagnosis without assessment......just like the other patient.....What is your assessment? What are the vitals/labs...tell me about your patient. What is going on what do they NEED?
    psu_213 likes this.
  7. 1
    In nursing school sometimes you have to make diagnosis before youve had any contact with the patient or have looked at their labs..you are given a few bits of data and make a tentative plan on the expected priorities..I know I had to many semesters
    GrnTea likes this.
  8. 0
    I know and that makes me sad. I think that is where students have trouble.

    However, the OP states....
    I had this patient this week
    ...past tense and it's now Saturday....they probably have more information which needs to be considered first.

    OP...lets start from scratch like the previous one.....tell me about your patient...
  9. 0
    Labs are data, admission notes are data. You can always use them even if you don't know all you will later.

    OP: I am sure you've seen this before, but you can probably benefit by seeing it again

    You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.


    There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.


    A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."


    "Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."


    To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!


    If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:
    1, health promotion (teaching, immunization....)
    2, nutrition (ingestion, metabolism, hydration....)
    3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)
    4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)
    5, perception and cognition (attention, orientation, cognition, communication...)
    6, self-perception (hopelessness, loneliness, self-esteem, body image...)
    7, role (family relationships, parenting, social interaction...)
    8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)
    9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)
    10, life principles (hope, spiritual, decisional conflict, nonadherence...)
    11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)
    12, comfort (physical, environmental, social...)
    13, growth and development (disproportionate, delayed...)


    Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.
  10. 0
    I believe fluid volume deficit would address the bleeding. Would we not do similar things to each of these diagnoses?
    Decreased cardiac output r/t bleeding
    Ineffective tissue perfusion r/t bleeding
    Fluid volume deficit r/t bleeding

    While the label is different, the cause/etiology is the same.

    We would:
    Administer O2
    Obtain Type and Crossmatch
    Administer fluids (LR, NS, etc)
    Administer PRBCs or platelets
    Prepare for endoscopic treatment, TIPS surgery, elastic band
    Initiate fall precautions ( r/t to thrombocytopenia, bleeding risk)
    Administer clotting factors (I don't know this though)
    Administer Meds that address portal vein HTN
    Etc, Etc, Etc

    Again, while the label/diagnosis is different, we would do similar interventions. Yes, there are unique interventions depending on cause/etiology. You would be more accountable to having the correct diagnosis, IF, there was assessments. However, addressing the problem with any of these diagnoses would be sufficient considering the common interventions. IMO. Good Luck!

    -Andrew
  11. 0
    Quote from Floridatrail2006
    I believe fluid volume deficit would address the bleeding. Would we not do similar things to each of these diagnoses?
    Decreased cardiac output r/t bleeding
    Ineffective tissue perfusion r/t bleeding
    Fluid volume deficit r/t bleeding

    While the label is different, the cause/etiology is the same.

    We would:
    Administer O2
    Obtain Type and Crossmatch
    Administer fluids (LR, NS, etc)
    Administer PRBCs or platelets
    Prepare for endoscopic treatment, TIPS surgery, elastic band
    Initiate fall precautions ( r/t to thrombocytopenia, bleeding risk)
    Administer clotting factors (I don't know this though)
    Administer Meds that address portal vein HTN
    Etc, Etc, Etc

    Again, while the label/diagnosis is different, we would do similar interventions. Yes, there are unique interventions depending on cause/etiology. You would be more accountable to having the correct diagnosis, IF, there was assessments. However, addressing the problem with any of these diagnoses would be sufficient considering the common interventions. IMO. Good Luck!

    -Andrew
    Alas, the only nursing interventions in this list are initiating fall precautions and preparing for possibility of invasive medical interventions.

    Here's the deal.

    If you ever find yourself writing, "Administer meds/IVs/treatments/give blood/give oxygen/etc as ordered" (grrrrrr, I hate that word), all you have done is to say, "I will perform my legal duty to implement some aspects of the medical plan of care." (Other aspects, such as diagnostic radiology, lab studies, surgery, physical therapy, social work consults are not up to nursing to implement.)

    You have done nothing to indicate that you, the RN (to be) have a clue about what to do with a patient situation unless a physician tells you to do it.*

    Now, we all know that's not true. So...where would you look to find support for nursing assessment and interventions for nursing diagnoses, not medical assessment and diagnosis? Of course, there's some overlap-- nurses evaluate the effects of low hematocrit, bleeding, and thrombocytopenia too-- but we do not specify medical plans of care based on medical assessment. We write nursing plans of care based on nursing assessment.

    If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best resource you could have to start teaching you to think like a nurse (as opposed to an appendage of a physician). $29 at Amazon, $24 for your Kindle. Free two-day delivery for students. Order it now and have it in time for your weekend homework.


    *
    Your faculty is not interested in that, NCLEX is not interested in that, and that will not serve your patients.


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