In need of help with a nursing dx!!!

[Holly7824]

Hi everyone!! I am new to this site and I am in need of desperate help!! I am a second level nursing student and I am working on my case study. Here is so info on my patient:

65 yr old male, admitted through ER for generalized weakness and fever. He has had multiple admissions for Diffuse Large B-Cell Lymphoma, platelet count in the ER was only 16,000 so he has Thrombocytopenia. My nursing instructor told me that his priority nursing dx would be risk for injury. I have never wrote a nursing dx for this before and she told me to do the best I could, but like I said, I am doing my case study on this patient and this counts big time for an exam grade. So far I have for nursing interventions:

• Orient patient to the environment (side rails on bed, call light, bed positioning controls.
  
• Keep bed in lowest position and monitor at night very closely.
  

We also are required to use 2 nursing journals for each of our care plans to obtain the scientific rationales for our interventions. I have one nursing journal so far, but I have been searching all day online for another one and some other interventions for this dx. Can someone help me ASAP!!!!!! I greatly appreciate it!!!!

Holly

[elprup, BSN, RN]

PT would be a fall risk so you'd need interventions for that. Risk for infection - employees wash hands, standard percautions, etc. Monitor labs.

Those are the only ones I could think of at the moment. My advice - go out right now and get yourself a really good "Nursing Care Plan" Book. I used one by Gulanick/Myers called Nursing care plans; 6th ed. Helped out immensely!!! There are tons of things you could put, you just need to look and find them.

Also, google "risk for injury", I always googled everything and usually something would come up. Also check your school books, usually they have a section for care plans that as a student I never knew about.

Good luck, go get a care plan book, you'll be great.

plus it will help for teh following years.

[Whispera, MSN, RN]

for monitoring, use a specific timing, such as "will monitor at least every 15 minutes for safety." "very closely" doesn't say much, and can be interpreted differently by different people

[netglow, ASN, RN]

Holly, you say the patient has emergent low platelet count. Think what types of things regular patients can have done to them that would be contraindicated in this patient.:thnkg:

[Key_]

Don't forget to turn the bed alarm on!

[TxRn38]

In your nursing books look up thrombocytopenia...lung ca etc.

At risk for injury related to low platelet count . Examples of interventions to include:

patient teaching of fall preventions, siderails up x2 bed locked and in lowest position with call light within reach. Pt verbalized understanding to call for assistance. frequent nurse hourly rounds or prn.

Ensure pt uses clippers and non razors.

Pt reports black tarry gastric contents or stools, bleeding gums, or blood in urine. (If pt is unablt to report then nurse will monitor)

Monitor labs, ptt/inr/pt and vital signs.

Assess skin for petechiea (spell?)

Hope this helped a little. I learned alot by doing care plans, Good luck !

[IVRUS, BSN, RN]

Along with the aforementioned nursing interventions for thrombocytopenia,

remember to minimize excessive bleeding complications:

1. Avoid lifting heavy objects ( Don't want to break blood vessels with the strain)

2. Avoid forceful nose blowing

3. Stool softners may be indicated to avoid straining with defecation

4. Use soft toothbrush, instead of a hard bristled one

5. Avoid, or hold appropriate pressure to site after injections. Remember that the clotting cascade is 2-6 minutes, so if they have a low plt count they will be on the 5-6 minute side.

6. Electric razors vs. straight edged blades.

As far as the weakness and fatique,

1. Allow for frequent rest periods

2. Ambulate with a walker or behind a wheelchair

3. Discourage conversation if pt is SOB

4. BSC if unable to ambulate to bathroom at night

Hope these help!