3 part nursing Dx help!

  1. Hi guys, my patient scenario is: patient admitted to R/O CVA, complaining of headache 7/10 x 3 days, left arm and leg weakness, right side mouth droop, extremities cold, cap refill greater than 2 seconds, left pedal pulse dimished.

    I need help formulating a 3 part nursing dx. I made my number 1 dx ineffective tissue perfusion, peripheral but not sure if that's the best or how to connect the etiology. AEB could be dimished pedal pulse, sluggish cap refill but not sure about R/T.
    Any guidance is appreciated, thank you!
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  2. 3 Comments

  3. by   Castiela
    I personally would focus my nursing diagnoses on the neuro aspect of the patient; I can think of two that would be more pressing than tissue perfusion.

    As for the ethology of the cold extremities, without more information, it's hard to say. Are they always cold peripherally? Are they shunting away? What is their bp/ hr? Are they cyanotic? S it all extremities or just the left foot? I know you probably don't have all that information, but it is really hard to make a nursing diagnosis without it
  4. by   Tay1985
    Castiela, thank you. I initially wanted to go that route but I don't have enough information to form a 3 part dx... or at least I don't think I do. I'll keep re reading it and try to come up with something. Thank you!
  5. by   Castiela
    If you post the whole scenario I'm more than happy to look at it with you

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