Help with Nursing Care Plan, PLEASE??

well, the diagnosis that jumped out at me was a respiratory one, ineffective airway clearance. i recognized the symptoms immediately: non-productive cough and diminished breath sounds anterior rll and lll. the labored breathing with accessory muscle use is ineffective breathing pattern. however, if i read your post correctly, you must focus on the renal system, right?

every nursing diagnosis just like every medical diagnosis has a list of patient behaviors called cues or symptoms that we can observe and are characteristic of that specific nursing problem. nanda calls these cues or symptoms defining characteristics. a related group of cues and symptoms (defining characteristics) becomes a specific nursing problem and is given a label called a nursing diagnosis. only abnormal data can be used as cues or symptoms. the cues and symptoms you posted that might have anything to do with the renal nursing diagnoses are:

• oliguria - this is really a medical term and is diminished urination. my experience with esrd patients is they often produce no urine.
  
• fatigue
  
• bun 55
  
• creatinine 13
  
• phosphorous 8.2
  
• hgb 12.4
  
• hct 37.8
  

did you read about esrd? anemia is one of the complications. our renal failure patients often complained of nausea as well because of the buildup of toxins in their system. since diabetes is often an underlying cause the complications of diabetes are usually there as well including a number of pareses and neuropathies. these patients have fluid imbalances; one day they are fluid overloaded and the day after dialysis they are dehydrated. their skin has an unmistakable bronze hue to it which may be a tad difficult to notice in black patients but it can be seen in their eyes and nails. they may have pruritis. if you speak with them about it, they will tell you that that mentally they are just not thinking as clearly as they used to and that is because of the toxin buildup. the dialysis doesn't get all the toxins out.

did you review the medications that this patient was on? that is a good clue as to some of the problems that the doctor has had to address with him.

• ineffective tissue perfusion: renal r/t hypoventilation and decreased hemoglobin aeb oliguria, bun of 55, creatinine of 13, and phosphorous of 8.2.
  
• excess fluid volume r/t renal dysfunction aeb weight gain with water and fluid intake and no urine output.
  
• fatigue r/t renal dysfunction and anemia aeb lack of energy [need for rest, lethargy] and decreased hemoglobin and hematocrit levels. - an alternative is to use activity intolerance but you need respiratory and cardiac symptoms such as elevated rates of each with activity and patient needing to stop activity and sit down.
  

when you have a medical diagnosis break it down into its component signs and symptoms first because we can only use those to decide upon nursing diagnoses.

there is no bureaucracy involved. this concept map is merely helping you to work through the steps of the nursing process. nursing diagnoses, goals/outcomes and nursing interventions are all based upon the abnormal assessment data that you collect about the patient. that is all part of the nursing process. i attempt to explain this all the time to students on this thread: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. a concept map is one type of care plan. there are several others. they all incorporate the use of the nursing process.