I have a 36 yo patient in renal failure. He's on dialysis, producing no urine, has bronchitis, hypertension, congestive heart failure, is on 2L/min O2 via nasal cannula, and on remote cardiac monitoring. He presented with shortness of breath and headache but is being kept for observation due to his renal failure, bronchitis, and newly diagnosed congestive heart failure. His WBCs are high, RBCs are low, albumin is low, HGB and HCT are low; BUN and creatinine are WAAAY high and CO2 is high. For one of my nursing diagnoses, I want to put that he has ineffective renal perfusion but I have a few questions:
1. NANDA only has a "Risk for ineffective renal perfusion" diagnosis, not an actual ineffective renal perfusion diagnosis. Can I just take out the "risk for" part or would that not be acceptable? Clearly, I think this man is no longer just "at risk".
2. Would it be accurate to have my "r/t" part be hypertension and renal disease?
3. If I do take out the "risk for" part, what would my "aeb" part be? I was thinking about saying "aeb abnormal lab values and anuria; am I missing anything?
So would this be okay?: Ineffective renal perfusion r/t hypertension and renal disease aeb abnormal lab values and anuria.
Thanks so much in advance for any and all suggestions! (P.S. This is my first concept map/care plan due next week and it's a big part of our grade!)
Nov 26, '11
Thanks for the link Streamline! It looks helpful. I came up with this diagnosis...not sure if it's good or not: Ineffective renal tissue perfusion r/t hypertension and renal disease aeb decreased RBCs, decreased Hb/Hct, elevated BUN/Crt, anuria, and fluid overload.
Last edit by MomBak2Skool on Nov 26, '11