Does my nursing diagnosis make sense?

Nursing Students Student Assist


My patient is an older woman who fell while grocery shopping and broke her right hip. She had a right hip replacement. It's 2 days post op and her right pedal pulse is absent, however left one is present. She has edema in right foot and her dressing from her surgery is saturated in blood. History of CHF, hypertension, and afib. She is on warfarin.

I came up with the nursing diagnosis of "Ineffective peripheral tissue perfusion r/t hypertension, anemia, inactivity, and pt. taking warfarin AEB absence of pedal pulse in r foot, edema in r foot, blood saturated dressing, and lab results indicating low H&H."

Does this make sense or does it need to be revised? I didn't know if her CHF could be incorporated anywhere in it?


I would say the r/t would be surgery

Specializes in Public Health, TB.

Why do you think ineffective tissue perfusion is r/t hypertension?

In my nursing diagnosis hand book related factors for the diagnosis say hypertension

I don't think a related factor can be a surgery

Specializes in Varied.

It sounds like the r/t is 100% the surgery. Was her pulse absent prior?

It doesn't say anywhere basic assessment provided that it was

My first thought was compartment syndrome

Specializes in Inpatient Psychiatry.

That's a super long nursing dx. Assuming she had a pedal pulse before surgery, I'd go with something like "ineffective tissue perfusion r/t post-operative complication AEB absent pedal pulses on affected side" or something.

Also, if this is an actual case in a hospital, I sure hope someone contacted the HCP ASAP.

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