Ineffective protection

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Im working on my care plan and I need a little guidance. I have a pt who came in with a DVT and is on heparin and coumadin therapy. First, does my diagnosis sound alright?

Ineffective Protection r/t abnormal blood profiles secondary to anti-coagulation therapy aeb ptt greater than 150

Goal: Pt will remain free of bleeding

Also, I have about 10-13 interventions but they are almost all assessment and teaching.

So far I have:

Assess vital signs q4h

Monitor PTT q day

Monitor PT/INR q day

Adjust IV heparin rate q day per protocol

Assess for s/s of bleeding q4h

Assess for changes in LOC q4h

Teach client signs and symptoms of bleeding by day 3

Teach the client bleeding precautions by day 3

Teach client to avoid foods high in vitamin K

Teach client to wear medical alert bracelet by day 3

Avoid use of aspirin products/NSAIDS

what can I actually "do" to achieve my goal? Im not looking for a hand out but im really stumped. Thanks!

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Sorry if that was a little vague. By "do" I mean independent nursing actions.

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Specializes in ED.
Im working on my care plan and I need a little guidance. I have a pt who came in with a DVT and is on heparin and coumadin therapy. First, does my diagnosis sound alright?

Ineffective Protection r/t abnormal blood profiles secondary to anti-coagulation therapy aeb ptt greater than 150

Goal: Pt will remain free of bleeding

Ineffective protection from WHAT?

If pt is on both meds, why? And what else would we need to test?

Goals also need to have a time to be completed.

You teaching interventions don't necessarily need a "by day 3" note on there. I think you need to be careful with your wordings too Monitor and Asses can mean very different things and I've seen some teachers get real sticky about such things.

Have you looked through the Care Plan stickies at the top of this forum? There is some really great info in those threads.

m

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Ineffective protection from WHAT?

If pt is on both meds, why? And what else would we need to test?

Goals also need to have a time to be completed.

You teaching interventions don't necessarily need a "by day 3" note on there. I think you need to be careful with your wordings too Monitor and Asses can mean very different things and I've seen some teachers get real sticky about such things.

Have you looked through the Care Plan stickies at the top of this forum? There is some really great info in those threads.

m

Ineffective protection from bleeding. She is on heparin until her coumadin is up to therapeutic range and then she will be sent home. My instructors are very picky about time frames. If you dont have it for everyone you can consider it wrong.

I looked at the those threads but I didnt see much specific to my question. The only independent nursing action I have so far is:

Arrange room to reduce clutter q shirt

rationale: @font-face { font-family: "Arial"; }@font-face { font-family: "Calibri"; }p.MsoNormal, li.MsoNormal, div.MsoNormal { margin: 0in 0in 0.0001pt; font-size: 12pt; font-family: "Times New Roman"; }div.Section1 { page: Section1; } Pt's on anticoagulant therapy are at an increased risk for bleeding. An unorganized room with clutter will increase the chance of the pt bumping into an object and causing trauma. Keeping the room organized will ensure safe maneuvering and decrease the risk for bleeding.

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I found Ineffective Protection r/t altered clotting function from anticoagulant ( Ackley) but that's it. I would have gone with acute pain, immobility or ineffective tissue perfusion r/t interruption of venous blood flow. If she is aware of how dangerous a DVT can be then you have then got fear as an option as well.

Best of luck.

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