the breakdown in the tissue perfusion is in the guy's leg, not his kidney. i've given you 4 defining characteristics for ineffective peripheral tissue perfusion--the only abnormal data you really have. if you want to go strictly by nanda language the defining characteristics for peripheral would be:
- altered skin characteristics (hair, nails, moisture)
- skin discolorations
you've got your three for this diagnosis. you should also be able to fit in the treatments and symptoms of his dvt into this diagnosis as well.
i'm looking at the symptoms of his other medical diagnoses. he's got oxygen going which is probably related to his cad or atrial fib. i'm guessing that he probably gets short of breath with any movement. dyspnea also shows up in the symptoms for cad and atrial fibrillation. you should be able to use a nursing diagnosis such as impaired gas exchange r/t alveolar-capillary membrane changes aeb dyspnea.
your other defining characterisitics can be abnormal blood gases and you can also use skin pallor and/or abnormal breathing. there has to be a reason the doctor ordered oxygen for him.
i'm also thinking that he could get a diagnosis of decreased cardiac output since he's got atrial fib. it would be decreased cardiac output r/t altered electrical conduction aeb irregular heart rate, dyspnea and palpitations
[if he has these, as they are symptoms of atrial fib]
in any case, here is the list of his diagnoses with symptoms for them. if any of the symptoms apply to this patient--use them to help support your nursing diagnoses.
(polyuria, polydipsia, nausea, anorexia, polyphagia, headaches, fatigue, lethargy, reduced energy levels, muscle cramps, irritability, vision changes, numbness and tingling in extremities, abdominal discomfort)
(angina, nausea and vomiting, cool extremities and pallor, diaphoresis from sympathetic stimulation , fatigue, dyspnea)
(decreased skin temperature, dry scaly shiny atrophic skin, hairless skin over lower extremity, dystrophic brittle toenails, rubor of skin when leg dependent or elevated)
(pain, tenderness, fever, chills, edema of affected extremity, redness and warmth over affected area, palpable vein, lymphadenitis)
(weakness, fatigue, headaches, anorexia, nausea, vomiting, pruritis, polyuria, hypertension)
(deep aching joint pain, stiffness in the morning, crepitus in the joints, altered gait, contractures, decreased range of motion, joint enlargement)
(weakness, fatigue, forgetfulness, sensitivity to cold, constipation, unexplained weight gain, coarse dry flaky skin, periorbital edema brittle nails, decreased cardiac output, slow pulse rate, poor peripheral circulation, congestive heart failure)
(cervical spine disease)
(sleep disturbance, appetite or weight change, attention or concentration problem, fatigue, reduction in pleasure or interest, feelings of guilt, suicidal thoughts)
(dyspnea, dizziness, palpitations, exacerbation of congestive heart failure)
have you read over the information in these two stickys?
i don't know what your instructors are telling you, but the most practical thing you can do in terms of helping you with writing a care plan for any patient is to glean as much information from the patient's chart as you can get. that includes copying down signs and symptoms from the doctor's history and physical, any consultations, labwork results, evaluations by physical therapy, dietary, etc., results of x-rays and pathology reports. this is all assessment data. anything that is out of the norm is usable to support your nursing diagnostic statements as long as they are facts.