I need help prioritizing my nursing diagnoses.

[DanidelionRN, BSN, RN]

I am doing a Clinical Decision Making worksheet on my patient from clinicals this week, and I'm having trouble deciding which diagnosis is the priority diagnosis.

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My patient is an 83 year old male, who presented on 10/5 with right flank pain, and was diagnosed with pyelonephritis and an 8mm kidney stone. They did a right retrograde pyelogram and right ureteral stent placement. He has a history of chronic indwelling catheter use with self-catheterization, a history of kidney stones, hypertension, (though he presented at the emergency room with a BP of 88/46, and needed a bolus of saline solution to up his fluid volume), osteoporosis with spinal compression fractures, depression, bronchitis, esophageal reflux, lumbago, breast biopsy for gynecomastia,and is post- bilateral cataract removal, post thyroidectomy, and post inguinal hernia repair.

His vitals when i was caring for him on the afternoon of 10/6 were stable- 36.2C, P 98, R 20, O2 97 on 2L oxygen nasal cannula, and BP was 122/61. He had attained 1500ml on the incentive spirometer when I had arrived, but by the end of my clinical it had increased to 1850.

My physical assessment revealed that he had a pain rating of 4/10, had dark red transparent urine draining into his catheter bag, (which his wife and my nurse stated that the doctor was not worried about; he had been in to see the patient earlier that day) and diminished lung sounds. His heart rhythm was regular and he reported "occasional" tingling and numbness in his fingers. The nurse told me this was in his history, but it was not in the chart. He has an occasional nonproductive cough, and reported more dyspnea upon ambulating than was usual for him at home, though he has been on oxygen for a long time. His skin is intact, normally colored, and his capillary refill was less than 2 seconds. His peripheral pulses were present.

He is mildly hard of hearing, but communication was easy.

His HGB was low- 10.7; his HCT was also low- 31.3, and he had high WBCs at 11.7; sodium was mildly low at 134. BUN was 15, and creatinine was 0.90.

He had a braden scale of 22, and a fall risk scale of 3. He stated to me that he was not able to function much without his glasses, and felt blind without them. He was unsteady enough on his feet that therapy had considered getting him a walker, but they had not done it.

He was taking blood pressure medications (though as my teacher did not specify what medications to include for my project, i only ended up recording the ones that I was going to give- he had a large number of meds in the morning) that I believe included beta blockers. He was also on albuterol, O2, and a gentamycin antibiotic that was changed before I administered it, to an oral antibiotic- ciprofloxacin. He had Percocet 5/325 prescribed PRN q4hrs for pain; he had it at 2pm, and did not want any the rest of the shift; his pain level was 4 at around 2:45pm, but it was a "2 or 3" at around 6pm, when the pain medication would have been wearing off.

He is expecting to be discharged the following day- 10/7.

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My nursing diagnoses are:

Risk for infection: Related to respiratory stasis secondary to COPD, increased risk for exposure to pathogens secondary to the presence of a chronic indwelling urinary catheter;

Impaired gas exchange: secondary to COPD, evidenced by dyspnea upon exertion;

Acute pain: secondary to pyelonephritis, kidney stone, and surgical procedures involved in treatment;

Risk for falls: related to advanced age, poor eyesight manifested by patient's statement, and his history of cataracts, as well as the presence of an indwelling catheter, and an unsteady gait, and dyspnea upon excursion secondary to oxygen-dependent COPD.

I am not sure which one is more important; Pain is important because it affects everything else- healing, vitals, falls, etc- but his pain is pretty much under control and he's recovering pretty well- so I don't think it's the most important in his case at this point, though at one time, it was.

Impaired gas exchange is concerning- an increase in his dyspnea- but he is oxygenated well on 2L of oxygen, and is used to being on oxygen at home; he uses a portable tank (that is very small!) or his concentrator while at home. Since he seems to breathe well at rest, i wondered if this could be situational in part, being the extra stresses on his body causing an exacerbation of his symptoms? And what is there to do about it other than some patient teaching about COPD and self-care at home, seeing as he is going home tomorrow?

Risk for infection seems important, as he has had infections caused by his catheter in the past, has pyelonephritis now, He also has a history of kidney stones, which are a risk factor of pyelonephritis, and he also has COPD, and respiratory stasis can increase the risk for infection as well. The advanced age of my patient also plays a part, as the elderly can tend to have weakened immune responses.

Risk for falls is a diagnosis because of the unsteady gait of my patient, his poor vision without his glasses, the presence of a urinary catheter that he could trip on, his advanced age, which often is accompanied by slower reflexes, and his dyspnea on exertion, because if he becomes fatigued while ambulating or transferring at home, he is more likely to fall, than if he is not fatigued and dyspneic. However, his fall risk was rated as a 3 on the Hendrich's scale, and that is not significant enough to institute fall-risk prevention protocols; though he had a "Fall Risk Precautions" sign by his door on the unit.

So- of all of these, I would say risk of infection/spreading infection/future infection (however it best applies) is the primary diagnosis, and my first secondary diagnosis, I'm not sure; Pain is under control, gas exchange I'm not sure, and risk for falls, possibly #2, but then it leaves me with "risk for" as my top 2 dx and the two actuals as lower priority- so I'm not really sure I'm doing this right.

What do you all think? I have until Monday morning to finish this, (I have most of the rest of the assignment done).

[pharmgirl]

When I prioritize my care plan diagnosis I always go by the ABC's. If I can't go by the ABC's I use Maslow. Thats the way we were taught anyway

[Daytonite, BSN, RN]

i went through the list of information that you gave about the patient and the nursing diagnoses you came up with and you kept mentioning copd. this was not in the list of the patient's medical history. was this a new medical diagnosis? also, his primary reason for admission was right flank pain because of pyelonephritis and a kidney stone for which a stent was placed. he has abnormal dark red urine draining from his catheter and that needs to be addressed in your plan of care and i don't see that being addressed at all, particularly since you mention that he is being discharged the next day.

nursing diagnoses are based upon abnormal assessment data. that abnormal data, in effect, becomes the symptoms, or evidence, of the various nursing problems going on with the patient. you will eventually put a label on each of those nursing problems called a nursing diagnosis. this was the list of abnormal data i picked out from what you posted:

• pain rating of 4/10
  
• dark red transparent urine draining into his catheter bag
  
• diminished lung sounds
  
• has an occasional nonproductive cough
  
• reported more dyspnea upon ambulating than was usual for him at home
  
• was unsteady enough on his feet that therapy had considered getting him a walker
  
• he reported "occasional" tingling and numbness in his fingers
  
• mildly hard of hearing
  
• stated to me that he was not able to function much without his glasses, and felt blind without them
  
• high wbcs at 11.7
  
• taking blood pressure medications, beta blockers, albuterol, o2, gentamycin, ciprofloxacin, and percocet 5/325.
  

these translate into actual nursing problems and are sequenced according to maslow's hierarchy of needs:

1. ineffective airway clearance (diminished lung sounds, nonproductive cough)
   
2. activity intolerance (reported more dyspnea upon ambulating than was usual for him at home)
   
3. impaired urinary elimination (dark red transparent urine draining into his catheter bag)
   
4. impaired physical mobility (unsteady on his feet and needs a walker)
   
5. disturbed sensory perception, tactile, visual and auditory (he reported "occasional" tingling and numbness in his fingers, stated to me that he was not able to function much without his glasses, and felt blind without them, mildly hard of hearing)
   
6. acute pain (pain rating of 4/10, place of pain needs to be identified)
   
7. risk for infection
   
8. risk for falls
   

- - - - - - - - - - - - - - -

this is how your diagnoses should be sequenced (according to maslow's hierarchy of needs):

1. impaired gas exchange: secondary to copd, evidenced by dyspnea upon exertion;
   
   • you have no related factor
     
   • dyspnea on exertion is not good enough proof of a problem with gas exchange. it tells us there is more of a problem with activity intolerance.
     

[*]acute pain: secondary to pyelonephritis, kidney stone, and surgical procedures involved in treatment;

• you have no related factor
  
• you list no evidence of the pain
  
• this should say: acute pain related to inflammation of the urinary track secondary to pyelonephritis and kidney stone as evidenced by pain rating of 4/10 in the _____.
  

[*]risk for infection: related to respiratory stasis secondary to copd, increased risk for exposure to pathogens secondary to the presence of a chronic indwelling urinary catheter;

[*]risk for falls: related to advanced age, poor eyesight manifested by patient's statement, and his history of cataracts, as well as the presence of an indwelling catheter, and an unsteady gait, and dyspnea upon excursion secondary to oxygen-dependent copd.

[DanidelionRN, BSN, RN]

Thanks for the help... though according to my Carpenito-Moyet "Handbook of Nursing Diagnoses"- the only major defining characteristic of impaired gas exchange is dyspnea on exertion. Other htings are all "minor"- including confusion, three-point position, pursed-lip breathing, lethargy and fatigue, increased pulmonary vascular resistance, decreased gastric motility, prolonged gastric emptying, decreased oxygen content; decreased oxygen saturation, increaed PCO2, cyanosis.

The only thing on this list that is required is the dyspnea... for my diagnosis, i had dyspnea on exertion, as well as my patient's oxygen dependence (indicating that he has decreased ability to exchange gases with room air).

So- thank you for helping me prioritize them... but i thought I'd let you know that according to my book anyways, it's listed in a way that worked.