So ridiculous.

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Was almost done with my nursing care plan until my instructor tells me it's wrong and I should choose another nursing diagnosis! (sigh). Don't. Understand. General info on patient: Patient overweight. Consumes 4 oz liquid /day. No breakfast &snacks throughout the day. Eats 44% of meals but is overweight/ has HTN. Admit reason: pulmonary embolism as a result of deep vein thrombosis caused by bacterial knee surgery. Patient has contractures of upper extremities. Pain and edema in right leg (where thrombosis occurred). Patient refuses physical therapy. Immobile and gets up only to use restroom & bathe--both w/assistance. My dx taken from NANDA: Risk for skin integrity r/t chronic edema secondary to postthrombalitoc syndrome & immobility AEB pitting edema (1+). Subjective: Patient states she discontinued physical therapy. Objective: Patient immobile. Mobility occurs only to bathe and use restroom What is wrong with my DX?? Confused& stressed!!!

Specializes in GI, ER, ICU, Med/Surg, Stress Test Nurse.

I agree with the others focus on the ABC's.

May be this will help == in the back of my NANDA nursing dx book had a index, I could look up my priority medical dx and it would list the top priority nursing dx and I would look through those to find what was pertanent to my patient. Always keeping ABC's in mind, this worked for me most of the time but not always.

Specializes in Pediatrics.
These are what I have come up with so far. Let me know what you guys think. I appreciate all the help!

I can't use any words in my nursing diagnosis that would be a medical dx (ex. pulmonary embolism, hypertension)

1. Activity intolerance related to inadequate motivation secondary to pain

You're still dodging the real issue (and it sounds like your patient is too). However, not all of our patients are very savvy about consequences, hence the reason many of them get Into this mess.

If this patient had not already suffered a PE, then you could focus on all of the light and fluffy diagnoses (comparative to the actual physiological ones like cardiac and respiratory ones. But she the damage has already been done. While it may be difficult (since I'm assuming you are in 101 now) you have to think beyond the fundamentals, the skills you learn in 101 that you feel comfortable assessing. If you haven't covered PE in theory, take the time to look it up and understand it. We all know what pitting edema is, but do you know how it relates to CHF and cardiac output? Be proactive and go beyond your lecture and PowerPoint notes. Not only will it impress your professor, but you will learn something (and when you finally get to it in theory in the future, it will make more sense to you because you already applied it to a real patient)!

Specializes in Emergency.

Agree with above posters on the pe. For nursing dx, think about and focus on what's going to kill the pt. Then plot your dx in descending order from the most lethal possibilty. The risk fors come at the end.

I hated care plans but the idea is that by graduation you'll be able to do them quickly in your head.

Good luck.

You're actual problems are higher priortity than the 'risk for' ones, and of those actual problems its in ABC/Maslow order.

His breathing (pulmonary emboli) issue is of much higher priorty than his risk for impaired skin integrty. Think about it, his skin won't break down if he's not breathing (well, ok, if he stops breathing and never restarts, he's dead and sooner or later the skin WILL break down)..so who cares about that 'right now'. The patients pain trumps a risk for impaired skin integrity as does the obesity issue, and the edema

A(irway)...all ok, pt is breathing

B(reathing) focus on the pulmonary emboli and all the data that shows an issue with breathing (o2 sats, on o2?, resp rate etc)

C(irculation), edema, ummm patient only takes in 120mL per day?? Right there is an issue, (fluid deficit)

Pain-pt is complaining of pain..

overweight

so you see, risk for impaired skin integrity is the least of this patients worries right now. That's NOT to say its no a potential problem that can lead to bigger issues, but right now, the issues listed above trump a 'risk for' DX

This makes a lot of sense, but the only thing I'm worried about is that all of her airway, breathing, and pain problems are being treated (have been since she was admitted to the long-term care facility) with medications to which appear to solve any of those problems. This is what's making it hard. Her major problems are already being treated, so I wasn't sure if I could access those problems when there isn't a problem with them anymore. The only major problem that I can observe and what the patient tells me is pain in her leg because of swelling, osteoporosis which limits her ability to clean herself a/f BM, dress or feed herself. BUT this is being taken care of. The osteoporosis is something that can't be fixed. She refuses PT, b/c it brings more risk of pain than benefits. She doesn't consume fluids like she should but for some reason she's retaining water in her lower extremities. I'm not sure if she should consume more fluids with And again, I'm left with just edema. (booo).

This makes a lot of sense, but the only thing I'm worried about is that all of her airway, breathing, and pain problems are being treated (have been since she was admitted to the long-term care facility) with medications to which appear to solve any of those problems. This is what's making it hard. Her major problems are already being treated, so I wasn't sure if I could access those problems when there isn't a problem with them anymore. The only major problem that I can observe and what the patient tells me is pain in her leg because of swelling, osteoporosis which limits her ability to clean herself a/f BM, dress or feed herself. BUT this is being taken care of. The osteoporosis is something that can't be fixed. She refuses PT, b/c it brings more risk of pain than benefits. She doesn't consume fluids like she should but for some reason she's retaining water in her lower extremities. I'm not sure if she should consume more fluids with And again, I'm left with just edema. (booo).

Not all of her major issues are being treated (I bolded 3 major issues)...it maybe being taken care of but its not working if she's still complaining of pain. (Acute/Chronic Pain)

Not consuming fluids...is she dehydrated? What are her I&O's? What does her skin look like (dry, flakey, skin turgor good? Mucous membranes mosit and pink, dry? What are her BP's? Is she restless or anxious? what do her electrolyte labs look like? ) A decreased fluid volume can lead to all sorts of severe problems. (fluid volume, deficient)

Edema, no BOO to edema...problem...cardiac/circulartory (decresed cardiac output).

Specializes in Pediatrics.

Just because they are being treated doesn't mean you can't identify interventions. Care plans are modified all the time. How can you address her oxygen/tissue perfusion, gas exchange, cardiac output, etc in addition to what they're doing. Also, at least in my program, even if it is something that is already being done, we can include it as long as it is something we can do within our current scope of practice.

My LTC patient last semester was already on fall precautions. She was still falling multiple times per week. Hardly able to see and no fear of falling. Nobody had ever taught her and her husband what to do and why. My care plan was risk for fall because what had already been implemented was not effective, so you know what, lets try things again. The amount of teaching I did for her and her husband was immense. With her permission, we rearranged her room so it was less cluttered and easier to navigate. I really encouraged her to ask for assistance and informed her that she's not a bother, it is our job to help her when she needs it.

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