need help with CP/Dx

Medsport. . .your patient has 11 medical diagnoses! Do you mean to tell me that you didn't copy down any of the symptoms of these diseases from his history and physical exam in his chart?

Is the CSD celiac sprue disease?

I'm working on this.

ok, here's a nursing diagnosis to get you started. don't know if you need to include "secondaries" in your diagnostic statements, but i included it just in case. i've also given you two websites where you can get nursing interventions.

• ineffective tissue perfusion: peripheral r/t interruption of arterial flow aeb scaly skin on legs, edema of legs, reddened and discolored lower legs, and thinning hair over lower extremities, or
  
• ineffective tissue perfusion: peripheral r/t interruption of arterial flow secondard to pad aeb scaly skin on legs, edema of legs, reddened and discolored lower legs, and thinning hair over lower extremities

http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=55

http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_072.php

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:

• edema
  
• 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.

diabetes (polyuria, polydipsia, nausea, anorexia, polyphagia, headaches, fatigue, lethargy, reduced energy levels, muscle cramps, irritability, vision changes, numbness and tingling in extremities, abdominal discomfort)

cad (angina, nausea and vomiting, cool extremities and pallor, diaphoresis from sympathetic stimulation , fatigue, dyspnea)

pad (decreased skin temperature, dry scaly shiny atrophic skin, hairless skin over lower extremity, dystrophic brittle toenails, rubor of skin when leg dependent or elevated)

dvt (pain, tenderness, fever, chills, edema of affected extremity, redness and warmth over affected area, palpable vein, lymphadenitis)

renal failure (weakness, fatigue, headaches, anorexia, nausea, vomiting, pruritis, polyuria, hypertension)

osteoarthritis (deep aching joint pain, stiffness in the morning, crepitus in the joints, altered gait, contractures, decreased range of motion, joint enlargement)

hypothyroidism (weakness, fatigue, forgetfulness, sensitivity to cold, constipation, unexplained weight gain, coorifice dry flaky skin, periorbital edema brittle nails, decreased cardiac output, slow pulse rate, poor peripheral circulation, congestive heart failure)

obesity

csd (cervical spine disease)

depression (sleep disturbance, appetite or weight change, attention or concentration problem, fatigue, reduction in pleasure or interest, feelings of guilt, suicidal thoughts)

atrial fib (dyspnea, dizziness, palpitations, exacerbation of congestive heart failure)

have you read over the information in these two stickys?

• https://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - desperately need help with careplans (in nursing student assistance forum)
  
• https://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - careplans help please! (with the r\t and aeb) (in general nursing student discussion forum)

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.

Yes! Impaired tissue perfusion: peripheral will be #1 because of the oxygen circulation. The only thing that might trump it would be something like Decreased Cardiac Output depending on what makes up the components of it. If oxygen to the brain (as with an arrhythmia) is a concern, it bumps oxygen to the tissues of the leg, get it? Smart man!

Now, when you are looking at the self-care deficits think about what is going to happen if the patient gets no assistance at all with them. Nutrition is always going to be #1. No food, no life, you die. Nutrition (under Maslow) ranks second to oxygenation. I see most self-care deficits, however, falling under the area of comfort which is at the bottom of the list of physiological needs. And, among the ones you have, you can prioritize them within their own little group according to Maslow as well. Nutrition and feeding first, then elimination, then the hygiene ones (bathing, dressing).

You OK with this now? Do you think you understand where you are going with it? Hope you do an awesome job! This really is a kind of complex care plan because of the many problems this patient has. I wish wish you well.