Risk for thrombus formation as a NxDx

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    I am doing a careplan for an 83 year old client who has a decreased H&H and RBCs. She has a dx of hypoxic anemia along with ca. She gets dyspneic very easily, so she preferred to lay in bed. So I was thinking as one of my five NxDx to use risk for blood clot, but I cannot find it anywhere as a NANDA dx. Am I just not looking in the right place or is there no nxdx for risk for thrombus formation?
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  3. 5 Comments so far...

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    Blood clot is a medical diagnosis....besides increases in RBC makes you MORE likely to get a clot. Try risk for/ altered tissue perfusion, fatigue, less than body requirements...imbalanced nutrition if the anemia was iron deficiency related...

    Search for anemia related nursing diagnoses...i think youll have more luck.
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    I did have those when we were at clinicals and my instructor did not like them and told me to use decreased co and he said risk for clots, but I found risk for thromoboembolism. The reason he wants me to use it is because of her not getting out of bed and/or exercising, and it would be most pertinent for what would kill her today. But i appreciate the ideas.
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    Risk for peripheral neurovascular dysfunction?
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    Risk for thromboembolism is not a nursing diagnosis (I don't find it in the NANDA-I), and you can take your NANDA-I 2012-2014 to your instructor as proof. (free two-day shipping for students at Amazon...order it tonight and you'll have it in time for your care plan due Friday ).

    You could take a look at Risk for Injury, as it would include tissue hypoxia (which would be a result of a good whopping PE), Domain 11, Safety/Protection, Class 2, Physical injury, p. 430. Or perhaps (Impaired gas Exchange if she already has one...and what do you know about small emboli?), Look at the risk factors and I think you'll see at least two, maybe three, that would apply to your patient.

    This is a classic example of someone thinking about a medical dx (thromboembolism) and thinking it's a nursing dx. Sure, it's absolutely something we'd think about with a bedridden patient with other risk factors (high Hct/high plts/previous hx/malignancy (why? go look it up)/venous injury or insufficiency ... ) and we care about it not because we will be prescribing anticoagulants, but because we will be independently applying nursing measures (which are...?).
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    Quote from bengle115
    I am doing a careplan for an 83 year old client who has a decreased H&H and RBCs. She has a dx of hypoxic anemia along with ca. She gets dyspneic very easily, so she preferred to lay in bed. So I was thinking as one of my five NxDx to use risk for blood clot, but I cannot find it anywhere as a NANDA dx. Am I just not looking in the right place or is there no nxdx for risk for thrombus formation?
    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. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

    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.
    From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

    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: ADPIE

    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)

    So.....looking at your patient information for you have not provided an assessment.....
    83 year old client who has a decreased H&H and RBCs. She has a dx of hypoxic anemia along with ca. She gets dyspneic very easily, so she preferred to lay in bed.
    and that your CI wants you to use
    to use decreased co and he said risk for clots, but I found risk for thromoboembolism. The reason he wants me to use it is because of her not getting out of bed and/or exercising, and it would be most pertinent for what would kill her today
    First....risk of "thromboembolisim" is a complication/side effect/risk of bedrest it is not an actual NANDA I accepted diagnosis. So what would be......If your patient developed a blood clot in a blood vessel in the leg it would block the circulation...if you block the circulation you also cause....Ineffective peripheral tissue Perfusion.
    NANDA defines......Ineffective peripheral tissue Perfusion as a
    Decrease in blood circulation to the periphery that may compromise health

    With the Defining Characteristics that consist of.........Absent pulses; altered motor function; altered skin characteristics (color, elasticity, hair, moisture, nails, sensation, temperature); blood pressure changes in extremities; claudication; color does not return to leg on lowering it; delayed peripheral wound healing; diminished pulses; edema; extremity pain; paraesthesia; skin color pale on elevation
    With the (contirbuting factors) of....
    aggravating factors (e.g., smoking, bedrest) trauma, obesity, salt intake, immobility); deficient knowledge of disease process (e.g., diabetes, hyperlipidemia); diabetes mellitus; hypertension; sedentary lifestyle; smoking

    So......... your patient has the......

    Risk of ineffective tissue perfusion due to the development of thromboemboli from immobility related to the patients prolonged bedrest.

    Your patient gets
    dyspneic very easily
    so she has severe activity intolerance related to......

    NANDA I describes Activity intolerance as........
    Insufficient physiological or psychological energy to endure or complete required or desired daily activities

    With the Defining Characteristics of......
    Abnormal blood pressure response to activity; abnormal heart rate response to activity; EKG changes reflecting arrhythmias; EKG changes reflecting ischemia; exertional discomfort; exertional dyspnea; verbal report of fatigue; verbal report of weakness

    Related Factors (r/t)
    Bed rest; generalized weakness; imbalance between oxygen supply/demand; immobility; sedentary lifestyle.

    So your pateint has activity intolerance R/T porlonged bedrest, severs dyspnea, and severe anemia AEB (as eveidence by)....WHAT. What in your assessment of the patient would help you prove this diagnosis.

    So....if your patient has a decreased cardiac out put what would that cause? Hypotension? Shock?

    So your patient is at Risk for decreased cardiac tissue Perfusion (unless you have evidence that she actively has a decreased output.

    Risk for decreased cardiac tissue Perfusion


    NANDA-I Definition
    Risk for a decrease in cardiac (coronary) circulation

    Risk Factors
    Cardiac surgery; hyperlipidemia; hypertension; hypovolemia; hypoxemia; hypoxia; coronary artery spasm; cardiac tamponade; birth control pills; diabetes mellitus; drug abuse; elevated C-reactive protein; family history of coronary artery disease; lack of knowledge of modifiable risk factors (e.g., smoking, sedentary lifestyle, obesity)
    Tissue Perfusion: Cardiac as evidenced by: Angina/Arrhythmia/Tachycardia/Bradycardia/Nausea/Vomiting/Profuse diaphoresis

    Or does your patient have a Deficient Fluid volume causing a decrease of her cardiac output......Do you see where you are going?? Everything depends of the patient assessment. Tell me about your patient...what are her vitals, what are the labs? What else does she complain about...what brought her to the hospital.


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