Nursing diagnosis for unusual pulmonary embolism case

ClearBlueOctoberSky · Feb 26, 2012

I don't see why she is unusual for PE. Some of the risk factors for PE include smoking and obesity/being overweight. As a female and with four children already, is she on birth control? That will also increase her risk for DVT/PE, as would a history of HTN, coag disorders, and traveling.

As for your ND, think about the pathophysiology of the PE and what can happen. Sure she might be at risk for anxiety, but is she anxious right now? Would that be a priority diagnosis?

Do a search on ND. I know that there is some great help in the form of information on AN about how to proceed. I know from reading, that ESME12, has great information and has written about Care Plans and NDs.

Good luck.

momtofore · Feb 26, 2012

Thanks for your input.

She is overweight, but not obese so that's a contributing factor, but not overwhelmingly so. No birth control pills, no travel, no htn, no coag issues- in fact two years previously she hemorrhaged during her c-section. Smoker, that's it. (though bad enough, I know and yet physician said he didn't think that would be the cause)

She is definitely anxious now about future reoccurence and is stumped as to the cause, as is her physician. I've had other patients with DVT and PE and they had all sorts of risk factors and signs and symptoms and I was able to find multiple diagnoses. She's having no systemic reactions that I can see so don't know which way to go! Just truly stumped. I agree anxiety isn't much of a priority diagnosis, but it is her concern at this time.

I do know what CAN happen, but it isn't happening now. Those would be risk diagnoses then, right? Was trying to find something currently occurring. Any other thoughts?

ClearBlueOctoberSky · Feb 26, 2012

I would keep the anxiety r/t, although that is little further down your priority list. You can use a risk for, something like risk for ineffective tissue perfusion. Also think about the fact that she is being discharged on Lovenox therapy. What type of NANDA and teaching would be involved with a blood thinner that patient has no knowledge of, risks, benefits, how-tos, etc.

Mind you, I am a new grad LPN, with not alot of experience with care plans, aside from what I had to do in school. Hopefully one of the experienced RN will come along and give you some better ideas.

Good luck.

brillohead, ADN, RN · Feb 27, 2012

First thing that comes to mind is potential side effects from Coumadin/Lovenox. What could happen if she FDGB?

DOH -- Just noticed that ambgirl2nurse just posted the same thing!

momtofore · Feb 27, 2012

Exactly right, both of you. Thanks so much! I just wanted to be sure I'm not missing something systemic that I'm going to get dinged for! If there isn't, I can move into the others in peace....I hope, lol.

What is FDGB, btw?

nurseprnRN, BSN, RN · Feb 27, 2012

yeah, what is fdgb?

people who go home on anticoagulation need to understand what it is and why and how they take it; teaching is huge. please please please do not use the words "blood thinners." that puts people in mind of water in the milk or turpentine in the paint, and that is the wrong analogy. i have heard nurses say that "anticoagulation" is too big a word, but it is my experience that if someone can't repeat back to me what s/he has been taught, then using the words "clot" and "decreased clotting" is pretty clear. i know that somebody has already used them with her..make sure you tell her why it's not like putting water in the milk.

Esme12, ASN, BSN, RN · Feb 27, 2012

you have to know your pathophysiology of the disease process and treatment. pulmonary embolism (pe) is a blockage of the pulmonary artery or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream (embolism). usually this is due to embolism of a thrombus from the deep veins in the legs. a small proportion is due to the embolization of air, fat, talc in drugs of intravenous drug abusers or amniotic fluid. the obstruction of the blood flow through the lungs and the resultant pressure on the right ventricle of the heart leads to the symptoms and signs of pe. http://emedicine.medscape.com/article/300901-overview

symptoms of pulmonary embolism include difficulty breathing, chest pain on inspiration, and palpitations. clinical signs include low blood oxygen saturation and cyanosis, rapid breathing, and a rapid heart rate. severe cases of pe can lead to collapse, abnormally low blood pressure, and sudden death. symptoms of pe are sudden-onset dyspnea, tachypnea, chest pain of a "pleuritic" nature (worsened by breathing), cough and hemoptysis. more severe cases can include signs such as cyanosis, collapse, and circulatory instability due to decreased blood flow through the lungs and into the left side of the heart. about 15% of all cases of sudden death are attributable to pe

your patinet smokes......an actual risk factor for p.e. smoking cessation would be an actual problem

your patient is on anticoagulants what are the risks of those......what would you look for and educate your patient about. does she have and leg/calf pain. has she had a lower extremity doppler ultra sound? she is going home on lovenox.....is that what she is anxious about? what information does she need? so she has a knowledge deficit, right? about what? the disease process, her treatment, her dishcagre meds? is her anxiety related to giving shots at home? fear of beign unable to care for herself? fear of dying? is she still having pain?

think maslows hierachy of needs. maslow's hierarchy of needs - enotes.com virginia henderson's need theory

maslow’s hierarchy of needs is a based on the theory that one level of needs must be met before moving on to the next step.

self-actualization – e.g. morality, creativity, problem solving.
esteem – e.g. confidence, self-esteem, achievement, respect.
belongingness – e.g. love, friendship, intimacy, family.
safety – e.g. security of environment, employment, resources, health, property.
physiological – e.g. air, food, water, sex, sleep, other factors towards homeostasis.

assumptions

maslow’s theory maintains that a person does not feel a higher need until the needs of the current level have been satisfied.

b and d needs

deficiency or deprivation needs

the first four levels are considered deficiency or deprivation needs (“d-needs”) in that their lack of satisfaction causes a deficiency that motivates people to meet these needs

growth needs or b-needs or being needs

the needs maslow believed to be higher, healthier, and more likely to emerge in self-actualizing people were being needs, or b-needs.
growth needs are the highest level, which is self-actualization, or the self-fulfillment.
maslow suggested that only two percent of the people in the world achieve self actualization. e.g. abraham lincoln, thomas jefferson, albert einstein, eleanor roosevelt.
self actualized people were reality and problem centered.
they enjoyed being by themselves, and having deeper relationships with a few people instead of more shallow relations with many people.
they tended to be spontaneous and simple.

application in nursing

maslow's hierarchy of needs is a useful organizational framework that can be applied to the various nursing models for assessment of a patient’s strengths, limitations, and need for nursing interventions

care plan basics:

every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the nanda taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. you need to have access to these books when you are working on care plans. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics.

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
planning (write measurable goals/outcomes and nursing interventions)
implementation (initiate the care plan)
evaluation (determine if goals/outcomes have been met)

now, listen up, because what i am telling you next is very important information and is probably going to change your whole attitude about care plans and the nursing process. . .a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.

care plan reality: the foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. what is happening to them could be a medical disease, a physical condition, a failure to be able to perform adls (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. therefore, one of your primary aims as a problem solver is to collect as much data as you can get your hands on. the more the better. you have to be a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole nursing process.

assessment is an important skill. it will take you a long time to become proficient in assessing patients. assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. history can reveal import clues. it takes time and experience to know what questions to ask to elicit good answers. part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. but, there will be times that this won't be known. just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

a nursing diagnosis standing by itself means nothing. the meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient. in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are.

what i would suggest you do is to work the nursing process from step #1. take a look at the information you collected on the patient during your physical assessment and review of their medical record. start making a list of abnormal data which will now become a list of their symptoms. don't forget to include an assessment of their ability to perform adls (because that's what we nurses shine at). the adls are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. what is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. this is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

care plan reality: what you are calling a nursing diagnosis (ex: activity intolerance) is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition).

definition: insufficient physiological or psychological energy to endure or complete required or desired daily activities

(does this sound like your patient's problem?)

defining characteristics (symptoms): abnormal blood pressure response to activity, abnormal heart rate to activity, electrocardiographic changes reflecting arrhythmias, electrocardiographic changes reflecting ischemia, exertional discomfort, exertional dyspnea, verbal report of fatigue, verbal report of weakness

related factors (etiology): bed rest, generalized weakness, imbalance between oxygen supply and demand, immobility, sedentary lifestyle

one more thing . . . care plan reality: nursing diagnoses, nursing interventions and goals are all based upon the patient's symptoms, or defining characteristics. they are all linked together with each other to form a nice related circle of cause and effect.

https://allnurses.com/lpn-lvn-nursing/questions-about-writing-661965.html#post6052759 from daytonite...(rip)

you really shouldn't focus too much time on the nursing diagnoses. most of your focus should really be on gathering together the symptoms the patient has because the entire care plan is based upon them. the nursing diagnosis is only one small part of the care plan and to focus so much time and energy on it takes away from the remainder of the work that needs to be done on the care plan.

you may also like these resources...... i strongly suggest you budget for a good care plan book as you will need it...alot! i hope this helps.

nursing care plan | nursing crib

nursing care plan

nursing resources - care plans

understanding the essentials of critical care nursing

nursing care plans, care maps and nursing diagnosis

http://www.delmarlearning.com/compan.../apps/appa.pdf

cns: problem oriented nursing care plans

momtofore · Feb 27, 2012

Thank you for the extensive information and links, Esme12. I have been stymied because of the short-list of abnormal findings from assessment and diagnositic tests. Obviously the emboli, plus elevated d-dimer, smoking, overweight. I have done pathophys for PE and VTE so am fairly well-versed....for a newbie. I know i still have much to learn. I've had several patients in my limited experience under the umbrella of VTE.

No ADL issues...nothing, nothing, nothing going on other than those things I listed. BP, pulse ox, temp, pain, breath sounds, resp rate, GI, GU, integumentary, musculoskeletal, neuro....all normal- good even. Her anxiety is not so much about the therapy as the possibility of recurrence, or even death from the existing emboli as a young, close family friend just died from complications from emboli incurred from head trauma. This is why my main thoughts were anxiety, risks and yes, education (which was my main interaction with her). Just trying to see if I missed anything obvious given the four signs/symptoms I have to work with.

Thanks again! And feel free to set me straight if I'm on the wrong track!

momtofore · Feb 28, 2012

This is what I've come up with. I haven't prioritized them yet.

Risk for impaired gas exchange r/t decreased pulmonary perfusion associated with obstruction of pulmonary arterial blood flow by the embolus

Risk for recurrent pulmonary embolism r/t inadequate response to therapy

Risk for unusual bleeding r/t effects of therapeutic regimen ---OR---

Potential complication: bleeding r/t anticoagulant therapy

Anxiety r/t possibility of recurrent pulmonary embolism

Deficient knowledge r/t lack of information regarding anticoagulant therapy

Any tips?

ClearBlueOctoberSky · Feb 28, 2012

Yeah, sorry GrnTea, I really do use appropriate terms (most of the time:D). I apparently had a brain to finger disconnect.

ClearBlueOctoberSky · Feb 28, 2012

Thanks, Esme12. I really do wish I had spent more time on AN while I was in school, struggling with my care plans. You are just awesome!