Ineffective Tissue Perfusion

  1. 0
    I was wondering if I could use the NANDA Ineffective Tissue Perfusion for more than one specified type such as Renal due elevation in BUN/Creatinine ratio, Cardiopulmonary due to cap refill >3 sec and abnormal ABGs, and Gastrointestinal due to Abdominal pain/tenderness?
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  4. 1
    Yes, word it using your best English: Ineffective Tissue Perfusion, renal, gastrointestinal and cardiopulmonary R/T ______ AEB elevated BUN, creatine ratio, abdominal pain and tenderness, abnormal ABGs and capillary refill < 3 seconds. You do realize, don't you, that all you have is evidence of the Ineffective Tissue Perfusion? You still need a cause, or etiology, for this problem.
    Jarob747 likes this.
  5. 0
    Yes I do now, but before no I guess i didn't realize that. I am not sure what to put as the etiology. My patient is not on O2 and his sats are WNL. i just have evidence of decreased O2 carrying capacity because he has low Hbg and all that other stuff that I already mentioned. he is in for unknown abdominal pain. He has severe diarrhea, high risk for falls, decreased Cardiac output, Impaired urinary elimination, Acute Pain Imbalanced Nutrition more than body requirements and I put ineffective tissue perfusion. I don't know what to put down for the cause. Please Help.
  6. 1
    What is his medical diagnosis?
    Jarob747 likes this.
  7. 0
    Acute Abdominal Pain r/t unknown etiology
  8. 2
    determining the etiology of the physiologic nursing diagnoses is many times related to the pathophysiology of the medical illness. when you have abnormal data of an elevated bun and creatine ratio, abnormal abgs and abdominal pain and tenderness, and a capillary refill < 3 seconds you need to be careful how you start classifying these as nursing problems. knowing a little more, i would not call this whole shebang ineffective tissue perfusion. an elevated bun and creatinine ratio does not necessarily mean there is a tissue perfusion problem. you need to look at other evidence that is going on along with that. it could be any number of things: shock, trauma, dehydration, chf, hemorrhage, malnutrition, in addition to renal causes. nothing is ever cut and dried. when we diagnose we consider the patient's abnormal data as well as what is going on with them medically. i would probably consider acute pain before ineffective tissue perfusion. the abnormal abgs indicate a lung or acid/base problem and that is not a tissue perfusion issue either. why would they be drawing abgs on someone if they didn't suspect a breathing problem? abgs are not done as a routine on people because they are a very invasive procedure that involve puncturing an artery--and it hurts. i'd be getting in to see that patient and do a thorough history and physical assessment as well as glean the chart for the doctor's information on what he feels is going on for some direction on what might be happening.
    dinewnurse and Jarob747 like this.
  9. 0
    Thank You, I was kind of leaning more towards Acute Pain as my #1 problem but really his abdominal pain on the day that i had him was gone he only had tenderness in his RUQ and the only pain that he really had was due to his irritated, red, raw bottom from diarrhea. Dr ordered a stool sample but I was not able to obtain it because it was so runny and had too much urine in it as well. I just wish I had more than an 8 hr shift to try and do a whole care plan on. I want to really understand what is going on with him and right now I am just not. I really thank you for your help and I'm sure I will be asking for more here in the near future like umm prob tomorrow after clinical
  10. 0
    Just a quick thanks, Daytonite, for all the advising you do here on AN. People like yourself make this place the valuable resource it is.


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