Nursing Dx and care plan for risk of DVT

jesskidding, LPN · Nov 16, 2011

DVT is a med diagnosis ya? im just racking my brain.
patient with history of afib, chf
came in with c diff
i need two diagnosis and 4 interventions for each, risk for dehydration i have taken care of risk for dvt im struggling
1) risk for dehydration related to excess fluid loss as evidence by 5 loose bowel movements prior to admittance
2) risk of DVT related to lack of mobility as evidence by ???????
patient is on hep, aspirin how do i support this diagnosis?
haven't found any support so i need help,
heeeeellllp please, thanks
ian

I would start over with your nursing diagnosis for each. Do you have a good nursing diagnosis book? I can think of a few nursing dx that would be good. Do you have any other ideas and I will help you from there.

ireilly13 · Nov 16, 2011

sorry forgot to mention she was admitted for recurring c.diff, hence the risk for fluid volume loss and dehydration. I think i may go with risk for decreased cardiac output for the second.

1. Risk for deficient fluid volume related to excessive fluid loss as evidenced by 5 loose bowel movements prior to admission.

2. Risk for decreased cardiac output related to excessive fluid loss as evidenced by loose bowel movements

how does that seem?

yea i have a nurs diagnosis, that's where i found decreased c.o. I figure that with dehydration you'll have less fluid to pump and lower volume going in and lower c.o.

jesskidding, LPN · Nov 16, 2011

sorry forgot to mention she was admitted for recurring c.diff, hence the risk for fluid volume loss and dehydration. I think i may go with risk for decreased cardiac output for the second.
1. Risk for deficient fluid volume related to excessive fluid loss as evidenced by 5 loose bowel movements prior to admission.
2. Risk for decreased cardiac output related to excessive fluid loss as evidenced by loose bowel movements
how does that seem?
yea i have a nurs diagnosis, that's where i found decreased c.o. I figure that with dehydration you'll have less fluid to pump and lower volume going in and lower c.o.

Okay. Good start, but the pt has CHF, right? So, they would not be "risk for" they have passed that point. Therefore, the nursing dx would be more like; Decreased Cardiac Output r/t impaired cardiac function. As for the AEB I have not seen the pts chart, I am assuming you have so tell me why this would be a good nursing dx. What "evidence" do you have that the pt has impaired cardiac function?

As for the second one, I would go with something like; Deficient Fluid volume r/t to active fluid volume loss AEB....what? Again, what "evidence" do you have that to make this nursing dx correct?

Finish those and we can go from there. :)

ireilly13 · Nov 17, 2011

Good point.

Deficient fluid vol. r/t active fluid volume loss aeb loose bowel movements? her hct was low but not low enough to hold the heparin.

Could the decreased cardiac output be r/t decreased output and dehydration?

She came in with a second bout of c.diff and was on flagyl, vanco, some probiotics, aspirin, a ca- channel blocker, plavix. and hep 1mL q8h.

i was told the blood was to be kept thinner due to the risk for DVT.

Initially i wanted to the d(x) of decreased fluid volume and risk for dvt. I figured with C.diff that would be a primary risk. I was also thinking about the possibility of a superinfection from c.diff or maybe colitis from c.diff. Not sure if those would be more primary than dehydration. would risk for dvt be more primary than decreased cardiac output?

First time doing a care plan.

thanks for letting me bounce these off of you. :)

ian

jesskidding, LPN · Nov 17, 2011

DVT is a medical diagnosis. For this is be turned into a nursing dx you would have to do a nursing dx around anti-coagulant therapy and the risks associated there.

Okay, if you are want to go with the diarrhea then you would have nursing dx along the lines of; Diarrhea r/t Infectious processes secondary to Clostridium difficile AEB 5 loose stools per day, positive toxogenic stool culture (etc, etc, you get the point)

What are your long and short term goals realted to each nursing dx?

What are your nursing interventions for each nursing dx?

What teaching can you do r/t each nursing dx?

ireilly13 · Nov 17, 2011

so i think im going with risk for fluid volume defecit r/t active fluid loss aeb 5 loose stools

and the second im thinking i may go with risk for electrolyte imbalance.

man so flippy floppy with this

Long term i just want the lady to be cured of c.diff, her afib was converted 9/11, history of chf. but no lung complications, no edema, no lethargy, no dyspnea. The c.diff was HA a two or so months before and this is a recurrent episode so what could be recommended long term for a patient like that? Would that mean i should look at a different diagnosis, one that will provide for long term goals? I'll stop thinking so much and focus on 1. risk for dfv etc etc. and 2) risk for electrolyte imbalance r/t fluid loss aeb loose stools. My concern with that though is number 2 is related too and evidenced by the same as #1 . Am i overthinking this too much for my first care plan? goals i can pull from my awesome nursing diagnosis handbook from evolve and i can pull interventions from there as well. Teaching r/t each diagnosis is a good question. i would educate the patient on the importance of a well hydrated body, especially for a person with a history of afib; gotta keep every variable working properly and a well hydrated body will be a first line.

jesskidding, LPN · Nov 17, 2011

so i think im going with risk for fluid volume defecit r/t active fluid loss aeb 5 loose stools
and the second im thinking i may go with risk for electrolyte imbalance.
man so flippy floppy with this
Long term i just want the lady to be cured of c.diff, her afib was converted 9/11, history of chf. but no lung complications, no edema, no lethargy, no dyspnea. The c.diff was HA a two or so months before and this is a recurrent episode so what could be recommended long term for a patient like that? Would that mean i should look at a different diagnosis, one that will provide for long term goals? I'll stop thinking so much and focus on 1. risk for dfv etc etc. and 2) risk for electrolyte imbalance r/t fluid loss aeb loose stools. My concern with that though is number 2 is related too and evidenced by the same as #1 . Am i overthinking this too much for my first care plan? goals i can pull from my awesome nursing diagnosis handbook from evolve and i can pull interventions from there as well. Teaching r/t each diagnosis is a good question. i would educate the patient on the importance of a well hydrated body, especially for a person with a history of afib; gotta keep every variable working properly and a well hydrated body will be a first line.

Yes, you are over-thinking it.

Good luck. I tried to help!

ireilly13 · Nov 17, 2011

you did help. thank you :)

Somewherenear · Nov 17, 2011

A risk for diagnosis does not need an 'as evidenced by' part... so you can actually tweak your diagnoses by cutting off the "aeb" part and just leaving what follows as a second related to.

Also, with a patient who has diarrhea -issues to be concerned with include:

1. Nutritional status

2. Hydration/Fluids and Electrolytes

3. Impaired skin integrity - irritation in perineal area

4. Pain? - Cramping with the diarrhea? Passing any blood?

Hopefully those four points can help you write four nursing diagnoses.

As for your concerns regarding the risk for a DVT - you would probably be better off writing a diagnosis relating more to the patient's response - for example - ineffective therapeutic regimen management related to heparin therapy as evidenced by patient unsure of how to do self-injections of heparin, patient unsure of what signs/symptoms to notify HCP of (bleeding, excessive bruising), and patient not knowledgeable about purpose, action, side-effects of medication.

Good luck to you!