In need of help with a nursing dx!!!

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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

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Specializes in ICU.

Well if he is a risk for injury, I would make sure he is always wearing the non slip booties/socks.

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offer toileting every hour or two ( so he can be helped and not risk him getting up by himself)

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Due to the low platelet count, I would include bleeding precautions, such as pressure on injection sites, No IM injections, soft toothbrush, monitor closely for bruising, change in LOC, etc.

Here's a pretty good care plan site.

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/#New

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