DLF1021

Peyton013, Other possibles that do not include risk for may be fear, anxiety, or perhaps impaired tissue perfusion? I'm still trying to muddle my way through these care plans myself...hope this sparks an idea for you!

Hello, I am a 3rd year BSN student and I just started clinical this fall. I am currently working on my first full care plan and am having difficulty coming up with good nursing diagnoses as my patient really wasn't all that "typical". 78 yo female (appearance and mobility of a 60-something) presented with DVT of LLE and PE. Denied difficulty breathing (pulseox 97% on RA) but complained of "pinching sensation" at right side, about breast level. On admission, LLE had +4 edema but patient denied pain. Stated that she wouldn't have realized there was anything wrong if her pant leg hadn't become tighter. History of previous DVT (LUE) w/i last 6 months and recent (2 weeks ago) diagnosis of multiple myeloma...which explains her recent/present history of DVT. Pt was recently widowed and is living alone, though she has an active social life and "does everything" herself. At the time of my assessment, the edema of her lower extremity was at +1 with normal pedal pulses bilaterally and rapid capillary refill of the toes of both feet, she denied pain, and had no reports of respiratory complications. Though she was restricted to bed rest with permission to use the bathroom with assist, she was able to shift position in bed on her own, had no gait difficulties and reported no dizziness upon standing. Coumadin (1mg PO daily) and Heparin (25000u/250mL) as well as Percocet (5/325 Q4 PRN) were ordered though she had not asked for any pain medication. As far as a nursing diagnosis, I was able to come up with: Ineffective tissue perfusion related to interruption of venous blood flow secondary to DVT I also have Risk for falls listed, though I'm not even certain about this because she had such a steady gait and no history. Acute pain would have been an ideal one here but I really can't do that when every pain assessment I did yielded a 0/10 I also considered Risk for Powerlessness due to her recent diagnosis of muliple myeloma but I'm not certain that fits either. I would like to come up with 3 good diagnoses as well as interventions for each for her, but I am at a loss because nothing I can come up with really applies. She had no pain, no gait disturbances, no activity intolerances, which she should have given the extent of her condition. Any help for this novice would be GREATLY appreciated! Thanks, Deb