yet another care plan question!

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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

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Specializes in Hospice/Palliative Nursing.

I would cross reference nursing dx based on medical dx...that should give you a whole list of things to choose from. Not sure which nursing diagnosis book you are using but mine is set up with cross reference.

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Specializes in long-term-care, LTAC, PCU.

First of all, I would advise you to reference a good care plan book such as The nursing diagnosis handbook by Ludwig and Ackley, or Gulanick and Myers Nursing Care Plans. These books have an index of medical diagnosis' and prioritized nursing Dx and care plans that go with the medical dx. The other peice of advise I have is to always consider Maslow's Hierarchy of Needs when dealing with a medical care plan.

Always consider airway, breathing, circulation. In her case airway is not a problem, breathing is not a problem, however, circulation is a major concern. Your nursing diagnosis' should revolve around the circulation issues, and the complications that can result from these issues. I would forget the pain nursing dx because she doesn't have any pain, and the multiple myeloma is not related to the DVT/PE. Feel free to PM me and ask any other questions you may have. I hope this helped.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

welcome to allnurses.

care planning is about determining your patient's nursing problems and finding strategies to improve, stabilize or support their deterioration. to do that we use a tool called the nursing process which consists of 5 steps. the process begins by doing a thorough assessment of the patient.

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - you also need to know the usual tests that might be ordered as well as the medical treatments and complications of the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it. by pe you meant pulmonary embolism and not pulmonary edema, didn't you? besides looking up information about dvts you also need to look up information about a pulmonary embolism. i would encourage you to look up the signs and symptoms of a pe and dvt. there are more signs and symptoms that i think you may have missed, particularly with the pe. there is usually some kind of problem with activity and sob. just because the patient doesn't seem to have any of the symptoms of it doesn't mean she isn't at risk for complications. why, do you think, did the doctor not want her up and moving around? what will happen if that blood clot in her lung or leg moves? coumadin and heparin are anticoagulants that are being ordered by the doctor to treat the pe and dvt to prevent enlargement of the blood clot in her lung and leg. there are important nursing considerations associated with the administration of these drugs. they need to be included in a plan of care. and since the multiple myeloma is new, what might the patient want to know about it? how has the multiple myeloma affected what is going on with these problems? it has a poor prognosis. fractures, anemia and renal problems are complications of this disease. here is a thread that has a list of all kinds of helpful websites you can use to find information about diseases and their treatment: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites

  • dvt of lle
  • history of previous dvt (lue) within the last 6 months
  • pe
  • multiple myeloma (diagnosed 2 weeks ago)
  • on coumadin and heparin

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - this is the list i compiled from what you posted. why is it important to do this? because diagnoses are based upon evidence that you collect. if you see the evidence laid out before you it makes it easier to see the problems. as you get more experienced working with the nursing diagnoses you will start to see the symptoms of certain nursing diagnoses just screaming out at you.

  • complained of "pinching sensation" at right side, about breast level
  • lle had +4 edema (on admission)/+1 (at assessment)
  • pant leg had become tighter
  • restricted to bed rest with bathroom privileges with assist
  • recently widowed/lives alone

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - you need some sort of a nursing diagnosis reference to help you out with this.

you refer to the nursing diagnosis reference to find diagnoses that have the same defining characteristics (symptoms) that your patient has. if the definition of the diagnosis also matches with your patient's problem then you've found the right diagnosis. you can sometimes use medical disease cross references to help you narrow down your search so you don't have to look at 50 different diagnoses before finding the right one. you should always, however, check this taxonomy information (definition, defining characteristics, and related factors) before finalizing your diagnostic decision.

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

  • ineffective tissue perfusion, pulmonary and peripheral r/t obstructed pulmonary and venous blood flow secondary to blood clots aeb patient complaint of a "pinching sensation" in right side of chest at breast level and enlargement of left lower extremity and with +1 edema.
  • impaired physical mobility r/t prescribed bedrest aeb protected and slowed movement of left lower limb
  • acute pain r/t oxygen deprivation to lung cells aeb complaint of a "pinching sensation" in right side of chest at breast level.
  • deficient knowledge, multiple myeloma r/t lack of information aeb [???]

    [*]risk for injury r/t altered clotting factors

i was inclined to diagnose impaired home maintenance because of her recent widow status and the new diagnosis of multiple myeloma. it is possible that this patient will be discharged with home heath services--possibly. the future for her, however, is that she will eventually need care. so, this may be premature. however, i do feel it is important that she needs to be educated about this disease and its treatment. if she opts for chemotherapy in the future, she may need assistance.

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Specializes in Nursing School..

OK, I'M SORRY BUT ABOUT YOUR CARE PLAN QUESTION! That's just a little too odd because I have been searching all day long for help on this paper I'm doing right now for my clinical, I'm a second time, second semester student, we have these hudge papers to do on our patients that include care plans and for the first time, I can NOT come up with a Nursing diagnosis! I think you will be able to relate to my set back here! TOO WEIRD!

My patient is an 82 year-old female who presented to the emergency department on 10-30-08 w/ complains of LLE pain, swelling and SOB for approximately 1 week, worsening on day of admission. Patient reports that she has also been increasingly SOB on exertion and had some mild pleuritic chest pain. Per patient's request, coumadin therapy was discontinued approx. 1 month prior to admission.

PATIENT HAS A SIGNIFICANT PAST HISTORY OF DVT OF THE RLE SUBSEQUENT TO MASSIVE PE THAT REQUIRED EMERGENCY EMBOLECTOMY.

Upon admission to facility patient was symptomatic with acute on chronic anemia agreed to transfuse 2 units PRBC. Patient will require life long anticoagulation therapy. (THIS WAS ONE THING I CAME ACROSS FOR A DIAGNOSIS, BUT I SAW IT MORE AS A RISK FOR, AND WE CAN NOT USE RISK FOR'S)

IF ANYONE CAN HELP ME OUT TOO, IT WOULD BE SOOOO APPRECIATED CAUSE I'M JUST AT A LOSE HERE,

I too came up with ineffective tissue perfussion, then I kinda said looked at both DVT and PE and asked my self, which one is more life threatning, PE! So then I revised and came up with sudden death! cause you have that golden hour, that falls under risk for!

AAAAAHHHHHHH! I DONT KNOW!!!! OMG I suppose you all want to know what her actual diagnosis was! duh,

patient was admitted to the hospital with recurrent episode of DVT with PE!

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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!

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Specializes in Nursing School..

yea I hate care plans! I used ineffective tissue perfusion; pulmonary and peripheral R/T obstructed pulmonary and venous blood flow secondary to venous thrombi As evidenced by patient complains of pain in LLE, tenderness on palpation in LLE, positive Homen's sign in LLE, swelling and +1 pitting edema in LLE, SOB and dyspnea on exertion worsening on admission, pleuritic chest pain, past history of DVT and massive PE subjected to embolectomy, tachycardia, D-dimer H at 16.42, Doppler studies of LLE presenting thrombus within common femoral, superficial femoral and popliteal veins, and posterior tibial vein demonstrating little flow. There is also a thrombus within the saphenous as well. Thats my nursing diagnosis part of my care plan, I dont know if I can actually use both the pulmonary and peripheral in one diagnosis like that, but I figure I will give it a go! I'm having a problem with my Nursing Interventions too. I found some online but I only found the one's for circulatory, so I don't know if I need more or not, I don't have any Interventions that say anything about the teds? I hate care plans!

Well Good luck to you!

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