Jump to content

paraplegic pt. diagnoses help

Posted
by Deezywheezy Deezywheezy (New) New

I have a pt. that I have to write a careplan on who is a paraplegic and I'm not really sure about what diagnoses to pick. This pt. came in because they had bilateral DVTs and when they were admitted they found out this pt had a UTI. The pt. was using a foley catheter at home and was on a foley in the hospital as well but that was d/c and a straight cath will be used instead.

The two priority diagnoses that I was thinking of was ineffective peripheral tissue perfusion and impaired urinary elimination but like I said above i'm not really sure if these are the best ones to pick. Are there any better ones? or are these good?

Any help will be greatly appreciated! Thank you!

PsychNurseWannaBe, BSN, RN

Specializes in LTC, Nursing Management, WCC. Has 13 years experience.

What would be your r/t and AEB?

Ineffective Peripheral Tissue Perfusion r/t paraplegia and second hand smoke exposure AEB HCT 31.6L, HGB 10.9 aptt-heparin: 57.1. Absent pedal pulses only heard w/ doppler and were weak b/l. puffy legs w/ +2 edema b/l, cap refill >3 sec b/l. Pt. not unable to move from the waist down.

situational low self esteem r/t loss of independent functioning AEB poor eye contact, quiet, withdrawn, dull affect, consulted psycho for depression- prescribed cymbalta.

reflex urinary incontinence r/t neurological impairment above level of sacral AEB no sensation of bladder fullness, inability to voluntarily initiate voiding, used foley catheter at home.

I'm kind of stuck on what to do... i think ineffective peripheral tissue perfusion is a definite because the chief complaint was bilateral DVTs. But I also wanted to do something with her UTI but i'm not sure what kind of diagnoses to give her...

actually, the dvts are not so much a cause of inadequate tissue perfusion, are they? how would venous clots slow or impair tissue perfusion, which is generally thought of as an arterial problem?

so for the dvt, think about what that puts him at risk for, both the condition and the meds they'll put him on for it; think about how you would watch for complications, teach him about his new med, and make his environment safe with it.

now. let's break this down:

"ineffective peripheral tissue perfusion r/t paraplegia and second hand smoke exposure aeb hct 31.6l, hgb 10.9 aptt-heparin: 57.1. absent pedal pulses only heard w/ doppler and were weak b/l. puffy legs w/ +2 edema b/l, cap refill >3 sec b/l. pt. not unable to move from the waist down."

is ineffective tissue perfusion caused by paraplegia? caused by 2ndhand smoke? not so much, i don't think-- marginal in the smoke, and temporary. does a low h/h and clotting study tell you how the paraplegia and the 2ndhand smoke cause problems? not really, either. at least not first-line problems.

now, though, if you rethink this, you're on to something with ineffective tissue perfusion, and i'd advise you to carry it a little further.

think about this: he has low oxygen-carrying capacity even if he has decent spo2 (low levels of red cells and hemoglobin to carry oxygen, and spo2 is only a percentage of the red cells carrying o2, not an absolute measure of how much oxygen is being carried).

did you know that paraplegia increases risk of cardiovascular disease? he has poor peripheral pulses, and his capillary fill is slow. he's edematous mostly because he has no venous pumping going on since his muscles don't work, unless he has an additional diagnosis of chf, which will make it worse.

so if a paraplegic has lousy tissue perfusion and no sensation, what does that put him at risk for? how would you assess for it? what nursing measures would you put into place to assess him and prevent those complications? how would you teach him about this, how to prevent it, and what to do if it happens?

I did a careplan that is similar to this

you should try these: ineffective peripheral tissue perfusion r/t immobility and risk for impaired skin integrity r/t immobility.

grantz

Specializes in Operating Room Nurse. Has 1 years experience.

Make it more complex and deadly.. Risk for tissue necrosis r/t altered tissue perfusion s/t CHF

Make it more complex and deadly.. Risk for tissue necrosis r/t altered tissue perfusion s/t CHF

When did the CHF happen? :eek:

Make it realistic for the actual patient.

Unless he's about to lose a limb (that hasn't happened either), this isn't appropriate. :)

grantz

Specializes in Operating Room Nurse. Has 1 years experience.

When did the CHF happen? :eek:

Make it realistic for the actual patient.

Unless he's about to lose a limb (that hasn't happened either), this isn't appropriate. :)

it is..heart failure is the heart failed to pump sufficient blood that should circulate to the system right? :D so therefore the tissues are not perfused adequately :smokin:

it is..heart failure is the heart failed to pump sufficient blood that should circulate to the system right? :D so therefore the tissues are not perfused adequately :smokin:

LOOK AT THE ACTUAL POST being asked about, please. This is someone's actual question about someone without CHF.

The only thing you're showing is inexperience. Joking around about someone in school looking for help is cruel.

grantz

Specializes in Operating Room Nurse. Has 1 years experience.

LOOK AT THE ACTUAL POST being asked about, please. This is someone's actual question about someone without CHF.

The only thing you're showing is inexperience. Joking around about someone in school looking for help is cruel.

Sorry about that. I'm just assuming that the thombus are dislodge that causes CHF. If my comment won't it's Ok I'll accept it. :cool:

PS Im not joking around ma'am

Sorry about that. I'm just assuming that the thombus are dislodge that causes CHF. If my comment won't it's Ok I'll accept it. :cool:

PS Im not joking around ma'am

OK....good to know :)

A thrombus dislodged is more likely to cause a pulmonary embolism or stroke. CHF isn't at the top of the list. :) Could be a complication of a PE....but not as likely in and of itself.

Edited by xtxrn

grantz

Specializes in Operating Room Nurse. Has 1 years experience.

OK....good to know :)

A thrombus dislodged is more likely to cause a pulmonary embolism or stroke. CHF isn't at the top of the list. :)

Thank you for clearing it up I'd rather edit it to make it more realistic but unfortunately I can't so maybe I'll just leave it their. :)

a dvt will not cause a stroke, although many people who have forgotten normal circulation anatomy think it will. follow the blood flow from leg to brain-- how would a clot get to the brain from there? is there another risk from dvt that would be more likely?

(an arterial thrombus, e.g., in a carotid artery or an intracardiac thrombus in the left heart, could cause a stroke, though.)

in terms of necrosis in peripheral tissues, is anybody here remembering that this is a paraplegic? hint, hint, hint.

if i don't see the actual answer by the end of tomorrow i will just have to tell you, i guess, but risk of this complication is so basic to paraplegia care that i'm astonished nobody has it by now. while accelerated cardiovascular disease will make it more likely, it's a huge risk in any para, young or old, recent or remote.

Pulmonary embolism

Pneumonia

Pressure sores/ulcers

????

(edited for spelling)

ding-ding-ding!

ding-ding-ding!

ding-ding-ding!

:yeah::yeah::yeah:

all three are causes of mortality and morbidity in sci! (and you can add sepsis from urinary tract infections and from pressure ulcers, two more)

(of course, none of these except pe have anything to do with the dvt, but are all so important with sci.)

a dvt will not cause a stroke, although many people who have forgotten normal circulation anatomy think it will. follow the blood flow from leg to brain-- how would a clot get to the brain from there? is there another risk from dvt that would be more likely?

(an arterial thrombus, e.g., in a carotid artery or an intracardiac thrombus in the left heart, could cause a stroke, though.)

in terms of necrosis in peripheral tissues, is anybody here remembering that this is a paraplegic? hint, hint, hint.

if i don't see the actual answer by the end of tomorrow i will just have to tell you, i guess, but risk of this complication is so basic to paraplegia care that i'm astonished nobody has it by now. while accelerated cardiovascular disease will make it more likely, it's a huge risk in any para, young or old, recent or remote.

respectfully disagree re: dvts not being able to cause a stroke. not common, but possible. :)

definitely agree with the pes, pressure ulcers, and pneumonia being big risks d/t immobility w/para.

i'm not able to get to my physiology book (and it's even one from this decade :D).... had to settle w/this.....for quick answer :twocents:

http://www.webmd.com/dvt/deep-vein-thrombosis-complications

body > [color=#2b4cdf]veins > vena cava > right atrium > tricuspid valve[color=#2b4cdf] > right ventricle > pulmonic valve[color=#2b4cdf] > pulmonary artery > lungs >pulmonary vein > left atrium > mitral valve > left ventricle > aortic valve > arteries > body

follow the above path. the only way a venous dvt can get to the cerebral arterial circulation is if there is a direct connection between the venous side and the arterial side in the heart and the venous pressure is higher than the arterial pressure.

anyone with an atrial or ventricular septal defect and a right-to-left shunt could be at risk for arterial embolus of venous origin, and this would be bad. however, since in most people, the left heart pressures are significantly higher than right heart pressures (by a factor of five to ten, more or less), any air or clot in the right heart keeps going right on out the pulmonary artery to the capillary bed. that strainer function is one reason you have a pulmonary capillary bed.

unsuspected asds are a known cause of stroke in younger people who lack other risk factors-- think of the much-beloved erstwhile heart and soul of the patriots' line, tedy bruschi, whose stroke fortunately resolved and whose asd was repaired endoscopically; he went back to football for the rest of that season and the next four (although he has since retired). as a matter of fact, most asds are found by accident or on post for unrelated issues, since the left-to-right shunt doesn't do much harm unless it's so huge that you get bad pulmonary hypertension and capillary bed damage (seen in single ventricle, for example).

Never heard of Tedy Bruschi :D I have heard of the risk of a CVA from a DVT for ages- never heard it was all that common- but that it wasn't impossible :) If the DVT in this patient blows, PE is the biggest risk, so I'm game to let it rest there. (however, I WILL get out my pathophys book when I can maneuver the stuff around it-LOL... I'm always looking to "relearn" a lot; I worked mostly neuro - and most of those CVAs were ICH, or atherosclerotic... also a lot of AVMs causing trouble. I've been up for 30 hours, so vocabulary isn't great right now :down:)...... In the interest of the OP, I'm signing out- (*&^ not being able to reach that book :D

I'm way past needing to come up with something for a care plan - and am probably too tired to attempt to think right now- but stasis ulcers would be an issue for someone not moving. My brain is mush.... :zzzzz

Edited by xtxrn