kynewbie

Hi All, Working on a care plan for my med-surge rotation and am confused about choosing a nursing diagnosis. My patient is cancer patient who was admitted to the hospital after developing a subclavian DVT (caused from her pic line, she said). So of course I have abnormal data and symptoms (pain in arm, discoloration, warmth, etc) and she is on Lovenox and warfarin. In discussing our cases at the end of the day, my instructor agreed with my diagnosis of risk for injury. Now as I am writing the care plan I am unsure what to put as my related factor or evidenced by. I thought we were saying she was at risk for injury "from the clot being dislodged", but when I look up info for this particular diagnosis, it seems the risk in from being on anticoagulants. So I am quite confused now about my diagnosis. Any help would be appreciated. Thanks!

Hi all, I am completing my maternity rotation and am having a hard time coming up with a diagnosis for my last patient. She is a 31 yr old, gravida 3, para 2, admitted because she was in discomfort and has previously had rapid labor once her water has broken. She has been in the hospital overnight and a pitocin drip was started at 0930. She is dilated at 4cm with 50% effacement and remained at that the entire day. She never established a regular contraction pattern and upon questioning the attending nurse, she said she was not in actual labor. The physician checked her while I was there and said he would not rupture her membranes until she had a more regular and stronger contraction pattern. She was only in mild discomfort the whole day. Her husband was there with her and provided great support. Her blood pressure and vitals were stable and withing normal limits. I have already written one care plan for alteration in comfort r/t child birthing process but am stumped as to what else to use. I have had better success writing my care plans since I have been writing them straight from my assessment data, but what do you do if there are no abnormalities? Any help would be greatly appreciated. Thanks so much.

See, this is why I get so tore up over care plans! I did not see anywhere in her chart where she has an active infection but she is on several antibiotics and antifungals. Basically all of her labs are abnormal!! Protein is 30, sodium is 133, chloride is 109.1, creatine is 1.3, calcium is 7.7, albumin is 2.3, I could go on and on. But based on her history of having a temp in the 100's for the past several days, she probably does have an active infection so that rules out the risk for diagnosis. I really need to get a care plan book. I only have my nursing books to look thru and they have a list of the diagnoses but none of the supporting data for each diagnoses, so I feel a little lost.

Hello, I am new to the forum as far as posting but have read many, many comments! I am writing a care plan for a patient with cll who is on neutopenic precautions. Her last chemo treatment was on 8/31 and her labs are as follows: T - 98.5 P - 87 & regular BP - 129/71 O2 - 98% WBC - 4.3 RBC - 2.94 Neut - 88.8% Lymph - 0.2% Mono - 0.1% Patient reports fatigue, nausea and vomiting in past 2 days. She also has +4 pitting edema of both legs. This is her second week in the hospital and she had an admitting WBC of 0.4. She has been running a temp in the 100's but that has finally stabalized today. I have to come up with 2 nursing diagnoses. I am thinking Risk for infection r/t decreased wbc. I have so much trouble doing care plans and I think it is because I try to make them more complicated that they really are. If I use the risk for infection diagnosis, would I use teaching infection control measures and diet, monitoring labs, I & O, administration of meds as interventions? What about a second diagnosis? Any help would be greatly appreciated. I stress so much over care plans.