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Need Help with nursing care plan



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Nov 04, 2009 10:23 AM

Need Help with nursing care plan


Here is what I have. I had a 5 m/o in end stage liver failure. Her platelet's were 27, PT 33 and aPTT was 120.6. In trying to come up with a care plan for her, i had a nursing diagnosis as risk for injury related to abnormal clotting factors AEB her test results(mentioned above). Is a suffiecient goal to show no signs of bleeding? Also, for the nursing interventions, should it be general info like strategies to prevent the problem from happening in the first place, monitoring for the specific signs of this problem reporting any symptoms that do occur to the doctor or other concerned professional? Thank you in advance for your help!


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2 Comments
No. 1
from rdsxfnrn
Old Nov 04, 2009, 10:52 AM

Default Re: Need Help with nursing care plan
5 m/o with end stage liver failure............???? she has bigger problems than bleeding............ an "at risk" dx should never be used first............... how bout altered comfort? pain? teaching family regarding impending death, impaired coping............ it does not always have to be about just the pt......... in this case too young and sick to absorb anything think oustside the box
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No. 2
from Daytonite
Old Nov 04, 2009, 10:51 PM

risk for injury related to abnormal clotting factors AEB her test results
A "Risk for" diagnosis is an anticipated problem, meaning that a problem does not yet exist. Therefore, there cannot be any AEB items in the diagnostic statement. If you have abnormal test results (platelet's of 27) then there is an actual problem to be addressed. A more appropriate nursing diagnosis to use for this would be Ineffective Protection R/T thrombocytopenia AEB platelet count of 27. Did the patient have any evidence of bruising, petechiae, bleeding from the gums, epistaxis or low back pain? These are other symptoms of thrombocytopenia.
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