Help, what is a nursing diagnosis for tranfusion

suzanne4, RN · Mar 22, 2006

You are looking at things in the wrong way to start. What is the problem that the patient has? The transfusion is the treatment, not the problem.

And if your patient had rhabdo, what concerns would you expect to see? Why do you even see it? What causes it?

Is your patient young or old? Young, rhabdo is usually found in someone who has been exercising quite a bit, stressing the long muscles of the body.

In the elderly, it is usually found in someone that was found down at home, and they were not seen for several days. The cells start to break down. And that goes along with the other diagnosis that you have of dehydration.

How high did their CK or CPK level get to? Some of these patients also require dialysis for a few days.

ICRN2008, BSN, RN · Mar 22, 2006

Risk for inadequate tissue perfusion?

suzanne4, RN · Mar 22, 2006

Why? They usually still have good pulses with rhabdo, unless severely dehydrated.

And that doesn't require a blood transfusion.

More thinking caps............

bookwormom · Mar 22, 2006

In a pinch, I would consider "altered protection" related to abnormal blood profile. However, Ineffective tissue perfusion: peripheral, related to decreased hemoglobin concentration in the blood does seem to fit better. Just because the pulses are good does not mean that there is enough oxygen getting to the periphery. Check the defining characteristics to see if any fit your pt. (My source is Wilkinson).

BTW, I was awful at careplans many years ago, but it all started to click after I graduated, and now I am a nursing instructor. So, hang in there.

snowfreeze, BSN, RN · Mar 22, 2006

Think prevention of the same problems happening again. Add some education for a healthier life for your patient as part of your careplan.

suzanne4, RN · Mar 22, 2006

With a diagnosis of Rhabdo, a healthier lifestyle doesn't come into play here. It occurs when the person has been exercising and stressing the muscles, same thing that you do when you are out running or at the gym; or they were found down and uncounsicious at home.

Healthier lifestyle doesn't work at all with this diagnosis.

snowfreeze, BSN, RN · Mar 22, 2006

Preventive health for rhabdo might include in the elderly to get a friend to check on them daily by phone or otherwise. This patient was also anemic and dehydrated so the younger rhabdo patient should be alerted to a better diet for anemia and to drink lots of water. We need to learn to pre-treat with teaching instead of just treating the problems later.

NephroBSN, BSN, RN · Mar 22, 2006

With a diagnosis of Rhabdo, a healthier lifestyle doesn't come into play here. It occurs when the person has been exercising and stressing the muscles, same thing that you do when you are out running or at the gym; or they were found down and uncounsicious at home.
Healthier lifestyle doesn't work at all with this diagnosis.

Because Rhabdo can be caused by drug abuse a healthier lifestyle could very well apply here.

It can also be caused by a crush injury.

suzanne4, RN · Mar 22, 2006

I have never treated a patient with Rhabdo that was a drug user, evey single one has either been at the gym or running, or found down at home.

With a breakdown of the cells you are also going to get an anemic patient, and they were not anemic proir to this episode. If they were that anemic, they would not be running or working out at the gym, they would not have the stamina for it. And that has nothing to do with dehydration.

My last patient, just a few days ago with this diagnosis, was over 60, and had been jogging, and actually tripped and fell into some cactus plants. He went home and was home for a few days, before coming in, because of swelling in his leg from the fall. He definitely was not dehydrated, and was never alone. His issue wias strictly from the jogging/running with the fall injury thrown in to the equation. CK was over 25,000 on admission, and actually peaked at over 64,000 before going back down.

And it was never stated if the patient was young or old by the original poster.

suzanne4, RN · Mar 22, 2006

And again, going back to the original post, it was asking about a blood transfusion. How that could be used as a nursing diagnosis.

maolin · Mar 22, 2006

Impaired gas exchange r/t decreased oxygen carrying capacity s/t anemia AEB H&H of ____, RR rate of _____, HR of ______, SpO2 _____, ABG's, transfusion of # units WB, PRBC, etc.

I'm a struggling nusing student, and my teacher hates my nursing care plans that we need to turn in for every patient we help take care of, this week I have a relatively stable patient, admit Dx is dehydration and Rhabdo, she been in the hospital for 3 days before I got to her, so her labs are practically back to normal, but she is anemic and need a blood transfusion, my question is what are the PRIORITY NURSING DIAGNOSIS for her and what can be my interventions?
Thank you