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

[Daytonite, BSN, RN]

Rather than Risk for Injury, I would use an actual problem diagnosis of Ineffective Protection R/T thrombocytopenia AEB generalized weakness. This can be substantiated by checking the related factors and defining characteristics for this diagnosis in the NANDA taxonomy. Your interventions will be to treat the weakness. You should be able to find interventions for those. You should also check references for other signs and symptoms of thrombocytopenia to see if you missed seeing any of them in this patient.

[Holly7824]

Thank you so much! I actually ended up using that diagnosis. My instructor had told me that his priority dx was risk for injury so I did that one too. Do you think by using those ones and using activity intolerance is good? Thanks again so much for all of your help!!

Holly

[Daytonite, BSN, RN]

Look at the NANDA taxonomy information for Activity Intolerance. This nursing diagnosis centers around respiratory and circulation problems and has to do with patients not being about to maintain an activity because they develop respiratory and circulatory symptoms. You didn't mention any in the data you gave about this patient. When a patient has activity intolerance they are deconditioned. They begin an activity and because they become short of breath and tachycardic they have to stop the activity and sit down. In some cases they are so weak that they cannot complete an activity and must stop it and sit down (deconditioned because of being bedridden, sedentary or immobile for a long time). Your patient must have the symptoms first in order to diagnose any problem. This is why you must assess first.