CLIENTS NURSING CARE PLAN FORM

Nursing Diagnostic Statement Rationale or Nursing Diagnosis Client Goals

!"Ris# or $lee%ing r&t irritation
o air'a( secon%ar( to
lar(ngeal mass) anticoagulation
t*era+() an% iron %eicienc(
secon%ar( to anemia"
,
Literature,$ase% Rationale or Nursing Diagnosis Client Situation Rationale or Nursing Diagnosis
T*e nurse 'ill manage an%
minimi-e $lee%ing e+iso%es
.T*e +rinci+le com+lication o
anticoagulant t*era+( is s+ontaneous
$lee%ing an('*ere in t*e $o%("/ 0Da( et
al") !112) +" 3435"
T*e most common an% +otentiall(
%e6astating com+lication o
'ararin t*era+( is *aemorr*age"
An INR74"1 +laces t*e +atient at a
greater ris# o a $lee%" Ol%er +atients
'*o incur an e+iso%e o
o6eranticoagulation ta#e longer to
return to a sae le6el) e8+osing t*em to
+otential $lee%ing com+lications"
Poor control o 9ararin ma( lea%
to increase% mor$i%it( an% mortalit()
re:uent %octor 6isits) longer
an% more re:uent *os+ital sta(s
an% resultant increase% *ealt* an%
*os+ital costs" 09esta'a() Cruic#s*an#)
Ro$erts) ; Esterman) !1<15"
.Anemia is a con%ition in '*ic* t*e
*emoglo$in content o t*e $loo% is
insuicient to satis( $o%il( %eman%s"
T*e con%ition usuall( is %ue to a %ecrease
in t*e num$er o circulating R=Cs/
0Lemone ; =ur#e) !111 +" <!>35"
.Treatment o t*e client 'it* anemia is
%irecte% to'ar% ensuring a%e:uate tissue
o8(genation" Common treatments or
clients 'it* anemia inclu%e
+*armacologic t*era+() %ietar(
mo%iications) $loo% re+lacement
G"P" is a >2 (ear ol% male '*o came to
t*e *os+ital 6ia E?S on @anuar( 1A) !1<B
'it* *emo+t(sis an% anemia" Citals 'ere
B>"4 C 015) >D $+m) <!<&D3mm?g E
$rac*ial) an% Sa1! AAF on room air on
a%mission" T*e +t *as $een coug*ing u+
$loo% or se6eral mont*s an% *as se6ere
%iicult( s'allo'ing an% consistent +ain
in *is t*roat" A $ronc*osco+( an% CT
nec# e8am 'as +erorme% Fe$ <<) !1<B)
s*o'ing a 4 cm mass on t*e let si%e o
t*e +atients lar(n8" Patient *as multi+le
lesions an% masses) e8cessi6e mucous
secretions) an% inlammation in t*e
t*roat" T*e +atients increase in coug*ing
an% lar(ngeal lesion is causing mo%erate
amount o *emo+t(sis" T*e +t 'as ta#ing
9ararin > mg PO %ail() $ut $ecause o
*is *ig* ris# or $lee%ing t*e %octor *el%
t*is me%ication" T*e +t is no' on D111
units Fragmin s&c %ail("
Client Outcomes
<"Client 'ill remain ree rom
e+iso%es o acti6e $lee%ing $(
<3&<&<B
, S#in or $ruising
,?emo+t(sis
, =loo% in stool
, Nose $lee%s
, ?ematuria
!" Clients 6ital signs remain at
$aseline $( <3&<&<B
B" Dis+la( la$orator( results or
clotting times an% actors 'it*in
normal range or in%i6i%ual $(
<3&<&<B
t*era+() or su++orti6e inter6entions/
0Lemone ; =ur#e) !111 +" <!315
4" Client 'ill $e e%ucate% a$out
action an% eects o
anticoagulation t*era+( $(
<3&<&<B $( s*o'ing an
un%erstan%ing o t*e reason *e is
on t*e me%ication 0treatment5
an% +ossi$le $lee%ing
a$normalities 0si%e eects5 suc*
as $lee%ing rom gums)
*emo+t(sis) $loo% in stool)
*ematuria) nose $lee%s
Inter6entions Literature,$ase% Rationale or Inter6entions E6aluation
Client Nursing
N,<G .Careul monitoring can %etect earl(
c*anges in $loo% 6olume/ 0Car+enito,Mo(et
!1<1) +" A<!5"
N,!G .Allo's or earl( %etectionH t*ese s(m+toms
in%icate t*at t*e $o%( is una$le to clot eecti6el(
an% urt*er e8amination an% inter6entions ma( $e
'arrante% to +re6ent *emorr*age/ 0Ro%gers) !113
+" 2<45"
N,BG .T*e t*era+eutic range or t*e INR is !"1,
B"1/ 0Car+enito,Mo(et) !1<1 +" AB!5"
NG4 .Ino'le%ge en*ances an8iet( re%uction an%
allo's t*e +atient to un%erstan% *ealt* status an%
im+lement *ealt*,+romoting $e*a6iors/
0Ro%gers) !113 +" 2<45"
N,D) C,!G .T*e +atient is at *ig* ris# or $lee%ingH
sim+l( $um+ing into o$Jects +laces t*e +t at ris#
or $ruising or ran# $lee%ing rom sim+le
inJuries/ 0Ro%gers) !113 +" 2<45"
C,<G T*e +atient '*o *as recei6e% t*rom$ol(tic
t*era+( or '*o is recei6ing anticoagulant t*era+(
is at ris# or *emorr*age %ue to alteration o
normal clotting mec*anisms" It is im+ortant or
t*e +atient to remain alert or e6i%ence o
$lee%ing" 0Lemone ; =ur#e) !1115"
C,BG T*e le6el o #no'le%ge o t*e main si%e
eect o 'ararin an% t*e signs an% s(m+toms o
$lee%ing $( +atients is +oor) in%icating t*e
maJorit( o +atients $eing %isc*arge% *ome
ater $eing commence% on 'ararin) lac#e%
a'areness o #e( as+ects o t*eir 'ararin
treatment" It is essential or +atients to *a6e
clear #no'le%ge on t*e signs o
Outcome <G Partially MET
T*e +t %i% remain ree rom acti6e $lee%ing
e+iso%es" T*e +atient still e8+eriences re:uent
e+iso%es o *emo+t(sis) *o'e6er" =ut t*is
$lee%ing 'as onl( a mo%erate amount t*roug*out
t*e %a("
Outcome !G MET"
Clients 6ital signs remaine% sta$le :4 *rs"
T B>"4 C 0O5 P >D $+m) 'ea# =P <!<&D3 mm?g
E $rac*ial) su+ine) R !4&min la$ore%) Sa1! A3F
on room air"
Outcome BG NO DATA AVAILABLE
T*e last INR la$ %ata 'as on <>&<&<B at <"!)
'*ic* is 'it*in normal limits
<3&<&<B R=C 4"42 0L5) ?g$ <<B 0L5) ?cT "B3 0L5
Outcome 4G MET
I *a% a %iscussion 'it* t*e +atient a$out *is
anticoagulant me%ications" ?e sai% t*e %octor
s+o#e to *im on <2&<&<B to e8+lain '*( *is
9ararin 'as $eing *el%" 9e %iscusse% t*e si%e
eects o anticoagulation t*era+( an% *e
un%erstoo% t*at *is me%ication 'as *el% $ecause
*e 'as at a *ig* ris# or $lee%ing" 9e also
%iscusse% saet( +recautions to ta#e to +re6ent
$lee%ing e+iso%es) an% t*ings to 'atc* or) suc*
asG $lee%ing rom gums) $lee%ing in urine or stool)
nose $lee%s) an% coug*ing u+ $loo% t*at 'as more
t*an usual or t*e +t"
Overall Goal: No serious $lee%ing e+iso%es
occurre% '*ile I 'as 'it* m( +t" ?e %i% *a6e
*emo+t(sis $ut t*is is usual or t*e +t" T*e
*emo+t(sis 'as onl( a mo%erate amount an% I
<"Client 'ill re+ort to
nurse an% $lee%ing
e+iso%es suc* as
,$lee%ing rom gums
,*emo+t(sis
,$loo% in stool
,*ematuria
,nose $lee%s
!" Pt 'ill a6oi%
acti6ities t*at increase
t*e ris# or $lee%ing
an% am$ulate careull("
,s*a6ing
,mo$ili-ing
,using a sot $ristle%
toot* $rus*
, trimming
ingernail&toes
B"Client 'ill e8+ress an
un%erstan%ing o
treatments)
me%ications) an% si%e
eects o
anticoagulation t*era+(
<"Nurse 'ill monitor
6ital signs or $aseline
6alues
!"Nurse 'ill monitor
or in%ications o
$lee%ing a$normalities
, S#in or $ruising
,?emo+t(sis
, =loo% in stool
, Nose $lee%s
, ?ematuria
B"Monitor la$orator(
6aluesG INR) C=C
4"Teac* t*e +atient an%
e6aluate *is
un%erstan%ing o t*e
ollo'ingG Treatments)
me%ications) an% si%e
eects o
anticoagulation
t*era+("
D" Encourage t*e +t to
am$ulate careull( an%
rerain rom *ig* ris#,
acti6ities"
$lee%ing" " 09esta'a() Cruic#s*an#) Ro$erts) ;
Esterman) !1<15"
inorme% t*e +t to noti( me i t*e amount o
$lee%ing increase% %uring t*e %a("