Need help with nursing diagnosis

[prettylynlyn]

I really need your help..

I need to make a nursing care plan for my patient.

I don't know what of her many problems will I use.

She mainly complains of difficulty in breathing at times..

When I checked her nails during physical assessment.. it was really pale and capillary refill was not possible..

I suspect poor tissue perfussion.

She also has a history of hematuria or blood in urine. =D

I don't know what to do..

Please help!

[lynzjo12]

Here is what I would suggest for the information you provided:

Ineffective tissue perfusion: cardiopulmonary: r/t impaired transport of oxygen aeb capillary refill > 3 seconds and any breathing characteristics (i.e. dyspnea, chest retraction, nasal flaring, use of accessory muscles, ect) .

[itsmyturn]

Ineffective tissue perfusion( renal) r/t poor exchange of cellular materials aeb difficulty breathing and hematuria?

You did not give reason for breathing difficulties...is it from resp, fluid overload, what? what was the reason for h/o hematuria...kidney prob, urinary tract, what?

[Daytonite, BSN, RN]

When you say you "need to make a nursing care plan" and the title of this thread is "need help with nursing diagnosis" do you mean that you need to pick one priority nursing diagnosis and develop a plan of care for it?

Based on what you posted respiratory problems are always a priority over anything else. So, I would diagnose Ineffective Breathing Pattern R/T fatigue AEB difficulty breathing. Your nursing interventions will be for the difficulty breathing.

Is this patient suspected of hemorrhaging or having some kind of blood loss? If so, it might be more appropriate that she is having a Deficient Fluid Volume R/T blood loss secondary to hematuria AEB pale nail beds and no capillary refill.

[itsmyturn]

ooh, your good and I want to be just like you when I grow up! :)

[slinger09]

Here is how I prefer to come up with my nursing diagnosis. Once I get an idea of what I think is going on I like to cluster all of my data that will back up this. You can refer to a nursing diagnosis book and see necessary criteria needed for the particular diagnosis. It sounds like you have a perfusion problem but your instuctor is probably going to want a little more than >3 capillary refill to back this up. First find all your abnormals you found in physical assessment, then go over lab values, also factor what kind of meds the patient is on, and then go over your H&P. Hope this helps.