Nursing Dx: Risk for DVT?

[amandaxyo, BSN, MSN, RN]

Hello,

Today in sim lab we had a situation where the patient was at risk for DVT because of immobility from surgery. When creating the nursing dx as a group, my peers suggested the nursing dx as "risk for DVT r/t surgery and immobility". I didn't think this could be used because DVT is a medical diagnosis ? is this a correct nursing dx? If not, what can be used instead?

thanks so much for your help!

[margin261]

Ok- long time since I made a care plan, so please double check this on a NANDA site, but you aren't dx'ing the pt with a DVT- just that theres a risk d/t immobility...

Your interventions are going to be along the lines of SCDs, turning, encouraging early ambulation (if possible), etc to decrease the risk

Care plans weren't my forte & I hated doing them!

[mrsboots87]

You are correct in that this is not a nursing diagnosis. The only acceptable nursing diagnosis come from the NANDA book and others that license some of the material from NANDA into a careplan book.

What at you are looking for is something along the lines of " Risk for ineffective tissue perfusion r/t interruption of blood flow s/t DVT." Or something like that. The NANDA book would have the correct diagnosis and causation factors.

Risk for DVT is a medical diagnosis which would require medical intervention. Nursing diagnoses focus on signs and symptoms of things to treat the person. Obviously the doctor will prescribe medical interventions for the nurse to perform, but the nurse will be thinking of the nursing interventions they may need to perform with the medical interventions prescribed if that makes sense.

[mrsboots87]

Also keep in mind that "r/t" equals caused by in nursing diagnosis world.

A surgery and immobility does not CAUSE a DVT. They are just increase the risk of developing one. What CAUSES a DVT is a clot. A clot causes impaired blood flow. The impaired blood flow causes ineffective tissue perfusion.

Think backwards when care planning.

Then for for interventions for a "risk for" diagnosis, thinks of the things that you can do as a nurse to prevent them. Early ambulatory, limb elevation, compression, ROM excersizes, monitor for the early signs of a DVT. You get the idea. Those become your interventionS for the diagnosis.

[amandaxyo, BSN, MSN, RN]

Thank you so much for clearing that up! :)

[NICUismylife, ADN, BSN, RN]

Are you guys using RCs yet? RC stands for "Risk for complication of ____" and you can then use a list of several high-risk complications (NANDA has a set list to choose from), DVT being one. If you are allowed to use RCs, then you can use "RC DVT r/t surgery & immobility" It is NANDA approved, but it has a very specific format, and you need to have approval from your instructor. We weren't allowed to use RCs until 3rd and 4th semester.