Care map help requested...

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I am having trouble with coming up with a nursing dx for my caremap. We have to come up with 3 nursing dx with 3 outcomes and interventions (2 short term and 1 long term). My patient was admitted with a DVT and has had a DVT last year also. She is 84 and uses a walker and has an unsteady gait. She has plus 2 edema on her left ankle and leg. He is on blood pressue medications, and has a history of chronic renal insufficiency, htn, gerd, asthma, heart murmur, hypothyroid, ht (not sure what this actually is??), and diverticulitis.

Would this be accurate? I have so far...

Nursing DX: Acute pain r/t edema as evidence by client stating "I have shooting pains from my left ankle to my calf" secondary to DVT.

Outcome: Client will state pain is

Intervention: Assess client for pain using the pain rating scale when doing vital signs.

Not sure about the outcome though...

Then I was thinking I could use risk of falls as a 2nd dx? Can anyone help me out? I just need a push in the right direction...

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what about:

Ineffective Tissue Perfusion: peripheral r/t interruption of venous blood flow

or

Pain r/t vascular inflammation, edema

(I'm just checking this book on nursing diagnoses)

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Risk for falls r/t unsteady gait comes to mind

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oop, didn't see your "fine print"... lol

Yeah, I'd go with that. :-)

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Specializes in Urgent Care.

Looks good!

I also like the inneffective tissue perfusion

What about risk for diagnoses? With all of the medical history you can do a few of those.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

in reading through your post i can only come up with 4 actual symptoms, or defining characteristics, that you have listed:

  • uses a walker for an unsteady gait
  • plus 2 edema on her left ankle and leg
  • heart murmur
  • shooting pains from the left ankle to the calf

since this patient has a dvt, what are the other symptoms beside pain in the leg? positive homan's? could you palpate a cord? did you get information from the doctor's history and physical exam and review of systems that would have provided you with more symptoms? i'm specifically referring to symptoms pertaining to the patient's hypertension, gerd, asthma and hypothyroidism. what kind of information did you get from the patient when assessing and interviewing the patient in regarding to these conditions? did you interview the patient about how she/he (wasn't sure of the gender of this patient) performs their adls? that's a very nursing thing to assess. all that information has the potential to become symptoms that will contribute to the formation of nursing diagnoses and a plan of care for this person.

you should also have a care plan or nursing diagnosis book to help you in formulating and properly choosing nursing diagnoses. if you do, i strongly urge you to read the first chapter(s) on the nursing process and the process of how to write a care plan. the way nursing diagnoses are chosen is usually discussed pretty extensively in these first chapter(s). each nursing diagnosis has a definition, symptoms (nanda calls them defining characteristics) and related factors. by consulting one of these books you match your patient's symptoms to the nursing diagnoses that are going to fit. it all begins with the assessment data you obtained.

based on the four symptoms you've listed i can formulate these three nursing diagnoses. i've included links to online nursing diagnosis information for each of them where you can get information on outcomes and nursing interventions:

you will note that your patient's symptoms become the items that appear after the "aeb" part of each nursing diagnostic statement. that's an important concept that you need to grasp. these same symptoms are the things that you are going to develop nursing interventions for. your outcomes are related to your predictions of what will happen as a result of performing those interventions. so, your outcomes should reflect an improvement, or sometimes just maintaining the status, of a symptom. what follows the "r/t" is always the etiology, or what is the cause, of the symptoms. it is not a medical diagnosis but more of a statement of pathophysiology of why the symptoms have occurred. when you use the words "secondary to" they are added after the etiology part of the diagnostic statement and they almost exclusively name a medical diagnosis. this is the back door, sneaky way that some nursing instructors allow students to show the relationship between the medical diagnosis and the nursing problems. don't use it unless your instructors have told you it is ok to do this. the nursing diagnosis, it's etiology and symptoms that support it are all related to each other.

you can find information about the nursing process and writing care plans on these two threads on allnurses:

what is important for you to pick up from this whole process is that the whole development of your care plan is based upon the data you collected during your assessment of the patient. this data can come from the doctor's history and physical, his progress notes, any diagnostic procedures that were done, lab results, respiratory therapy notes, physical therapy notes, dietary notes, social service notes, the nursing admission assessment, nursing notes and medication records, as well as what you observed with your own eyes and ears. if your assessment data isn't very good, then you are going to have problems with the care plan. how do you know? when you start to write the care plan things should fall into place because the care plan is a work that reflects rational critical thinking. when you are struggling to piece things together it is because you have missing pieces. those missing pieces are things that got passed over in the data collection. the thinking part of your brain realizes that, but you're not consciously able to see the error that you made. so, i'm here to tell you about it. the steps of care planning are rational and fit together like a lock and key. still, you have to know about each disease the patient has and how it is medically treated, what the medications are that will be given, what is normal physical assessment and what is not. so much needs to be known to put just one care plan together.

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Great post Daytonite, thanks! I too am learning how to write up careplans.

Focusing on the 2+ edema, I too would go with Ineffective tissue perfusion: peripheral r/t mechanical reduction of venous blood flow AEB 2+ edema.

outcome: Within 1 wk. pt. will demonstrate adequate tissue perfusion as evidenced by absence of edema.

outcome: Within 2 wks pt will identify changes in lifestyle that are needed to increase tissue perfusion.

intervention: elevate edematous legs as ordered and ensure that there is no pressure under the knee.

intervention: observe for signs of DVT

intervention: teach the importance of wearing compression stockings, elevating the legs at intervals and watching for skin breakdown on the legs.

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Specializes in Pediatrics, High-Risk L&D, Antepartum, L.

Outcome: Client will state pain is

2 things...

ht = hypertension

The other thing...we are not allowed to write an outcome that stated the patient will report a pain level of "fill in a number". That number is pointless without knowing if that number is okay with the patient. If the patient says 5 but 5 is fine by them then things are good. If they state a 2 but it's more then they can bare it's not good. So we are instructed to write something more like...Patient will report an acceptable level of pain or patient will report a decrease in pain level or patient will reported a decreased and acceptable pain level.

No numbers...too open ended since there's no way to know if that amount is okay and the goal is always to get it to an okay spot which varies in #'s from person to person.

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