diagnosis priority: exccess fluid volume or ineffctive tissue perfusion?

[ashleyisawesome, BSN, RN]

I'm working on my nursing process paper, and I'm trying to figure out which diagnosis would be more of a priority:

excess fluid volume r/t CHF AEB dyspnea, bilateral lower extremity edema, potassium level of 3.3 MEq (low), pleural effusion

OR

ineffective cardiopulmonary tissue perfusion r/t decreased hemoglobin concentration in blood AEB dyspnea, BLE edema, decreased urination, RBC count of 3.37, HGB count of 10.3, fatigue, respiratory alkalosis

I'm not sure if impaired tissue perfusion is caused by the excess fluid volume, or if the excess fluid volume is caused by the ineffective tissue perfusion. Can someone please explain it to me? and which one you would use as a priority diagnosis in a CHF patient who is in the hospital for SOB and severe BLE edema?

thanks!

[melmarie23, MSN, RN]

I'd go with the first, excess fluid volume-simply because of the ABC's. Difficulty breathing, to me, would be the highest priority. I might even redo that diagnosis to something of the following:

ineffective breathing pattern r/t compromised pulmonary function AEB pleural effusion, BLE edema and hypokalemia

or

impaired gas exchange r/t extravasation of extravascular fluid in lunch tissues and alveoli AEB pleural effusion, BLE edema and hypokalemia

[Daytonite, BSN, RN]

tissue perfusion diagnoses are always sequenced before the fluid diagnoses because they have to do with oxygenation of the tissues. with oxygen, the heart and lung tissues suffer pretty quickly and cause heart arrhythmias and death. it takes a few days for someone to die from fluid problems. however, there are also problems with the construction of your nursing diagnoses.

1. ineffective cardiopulmonary tissue perfusion r/t decreased hemoglobin concentration in blood aeb dyspnea, ble edema, decreased urination, rbc count of 3.37, hgb count of 10.3, fatigue, respiratory alkalosis
   
   • dyspnea belongs here as a symptom of this diagnosis
     
   • edema and decreased urination which you have here are symptoms of excess fluid volume.
     
   • pleural effusion, which is a medical diagnosis, and which you list as a symptom of excess fluid volume is what ineffective tissue perfusion: cardiopulmonary was intended to be used for. the gunk in the lung tissue (the effusion and chf) also impairs the transport of oxygen across alveolar and capillary membranes along with the low rbc and hbg counts.
     
   • i don't know that i would include fatigue as a symptom here. are you sure you don't have symptoms of activity intolerance that the fatigue goes with?
     
   • i would write this diagnosis as: ineffective tissue perfusion: cardiopulmonary r/t impaired transport of oxygen across alveolar and capillary membranes and decreased hemoglobin concentration secondary to chf and pleural effusion aeb dyspnea, respiratory alkalosis, rbc count of 3.37 and hgb count of 10.3
     

[*]excess fluid volume r/t chf aeb dyspnea, bilateral lower extremity edema, potassium level of 3.3 meq (low), pleural effusion

• you cannot use a medical diagnosis (chf) as a related factor in a nursing diagnostic statement. you must explain why there is chf in your "related to" section of this part of the nursing diagnosis. what is going on in chf?
  
• decreased urination belongs here as a symptom.
  
• how is the low potassium a symptom of overhydration (excess fluid volume)? you will find the symptoms of hypokalemia here: potassium.doc does it belong here as a symptom?
  
• you can't use pleural effusion because it is a medical diagnosis and it is related to chf and belongs with your other nursing diagnosis.
  
• i would write this diagnosis as: excess fluid volume r/t fluid retention aeb bilateral lower extremity edema and decreased urination
  

you can read about chf on this website: http://cvphysiology.com/index.html - cardiovascular physiology concepts, click on "heart failure" link at the left side of the page

[ashleyisawesome, BSN, RN]

wow thanks a lot. you really helped me out. i have a little trouble with these diagnosises.