Need help with Priority Nursing Dx

  1. 0
    I need help with the top 3 priority nursing dx! I kow it's ABC, but if the patient has no problem with those, what comes next? Help! This is what I have:



    1. Acute pain r/t SBO amb verbal report of pain, guarding behavior, facial mask, and expressive behavior.
    2. Imbalanced nutrition: less than body requirements r/t inability to digest food, increased metabolic demands, amb abdominal pain, body weight 20% under ideal
    3. Disturbed sleep pattern r/t anxiety amb verbal reports of not feeling rested and being dissatisfied with sleep.
    4. Nausea r/t SBO and pain amb verbal report of nausea.
    5. Anxiety r/t physiological factors (SBO), stress, and change in health status amb expressing concern and worry about current health status, fear of requiring another surgery, sleep disturbance, and decreased BP and pulse.
    6. Risk for infection r/t inadequate secondary defenses, pharmaceutical agents, and insufficient knowledge to avoid exposure to pathogens
    7. Risk for falls r/t presense of acute illness, anemia, impaired balance and medications
    8. Risk for injury r/t abnormal blood profile and chemical agents (alcohol consumption)


    Thanks!

    Last edit by julienurse2b on Apr 27, '13
  2. 8 Comments so far...

  3. 0
    Acute always before "risk for." Think pain and then Maslow.
  4. 0
    Don't quote me on this one but if the pt is anemic the pt does have available ABC diagnosis. Anemia=decreased RBC=decreased O2 carrying capacity=diminished tissue perfusion (circulation diagnosis).
    You also said pt has decreased BP and pulse. I think you need to look a little deeper at the patho behind those issues. You can find multiple diagnosis that relate and are more important than the typical "risk for" Dx.
    I'm having a brain fart so can you tell me what "amb" means? I don't think I'm familiar with that abbreviation.
  5. 1
    Is it "as measured by"? Or something like that. It's the substitute for "as evidenced by".
    babsy28 likes this.
  6. 1
    amb means as manifested by..

    Even though the pt has anemia, his O2 sat is 98 to 100% on room air. Besides an occasional low pulse and BP, there are no other defining characteristics for ineffective tissue perfusion.

    so i was thinking:
    1. acute pain
    2. Nausea
    3. risk for infection (neutropenia count is really low)

    What do you think? Also, the pt is NPO...
    Last edit by julienurse2b on Apr 28, '13
    babsy28 likes this.
  7. 0
    Quote from julienurse2b
    I need help with the top 3 priority nursing dx! I kow it's ABC, but if the patient has no problem with those, what comes next? Help! This is what I have:



    1. Acute pain r/t SBO amb verbal report of pain, guarding behavior, facial mask, and expressive behavior.
    2. Imbalanced nutrition: less than body requirements r/t inability to digest food, increased metabolic demands, amb abdominal pain, body weight 20% under ideal
    3. Disturbed sleep pattern r/t anxiety amb verbal reports of not feeling rested and being dissatisfied with sleep.
    4. Nausea r/t SBO and pain amb verbal report of nausea.
    5. Anxiety r/t physiological factors (SBO), stress, and change in health status amb expressing concern and worry about current health status, fear of requiring another surgery, sleep disturbance, and decreased BP and pulse.
    6. Risk for infection r/t inadequate secondary defenses, pharmaceutical agents, and insufficient knowledge to avoid exposure to pathogens
    7. Risk for falls r/t presense of acute illness, anemia, impaired balance and medications
    8. Risk for injury r/t abnormal blood profile and chemical agents (alcohol consumption)


    Thanks!

    Ok....first you decide what is important by using Maslows Hierarchy of Needs
    Five Levels of the Hierarchy of Needs

    There are five different levels in Maslow’s hierarchy of needs:

    1. Physiological Needs
      These include the most basic needs that are vital to survival, such as the need for water, air, food, and sleep. Maslow believed that these needs are the most basic and instinctive needs in the hierarchy because all needs become secondary until these physiological needs are met.
    2. Security Needs
      These include needs for safety and security. Security needs are important for survival, but they are not as demanding as the physiological needs. Examples of security needs include a desire for steady employment, health insurance, safe neighborhoods, and shelter from the environment.
    3. Social Needs
      These include needs for belonging, love, and affection. Maslow considered these needs to be less basic than physiological and security needs. Relationships such as friendships, romantic attachments, and families help fulfill this need for companionship and acceptance, as does involvement in social, community, or religious groups.
    4. Esteem Needs
      After the first three needs have been satisfied, esteem needs becomes increasingly important. These include the need for things that reflect on self-esteem, personal worth, social recognition, and accomplishment.
    5. Self-actualizing Needs
      This is the highest level of Maslow’s hierarchy of needs. Self-actualizing people are self-aware, concerned with personal growth, less concerned with the opinions of others, and interested fulfilling their potential.
    Care plans are all about your patient assessment....there is a glaring assessment that you need to address......Why is the patients B/P low? Why is the HR low? Qualify "low".
    Anxiety r/t physiological factors (SBO), stress, and change in health status amb expressing concern and worry about current health status, fear of requiring another surgery, sleep disturbance, and decreased BP and pulse.
    Wouldn't anxiety increase the patients HR and B/P?

    YOu have sufficient evidence for ineffective tissue perfusion....as you stated the patient had anemia. Qualify anemia.

    NANDA lists contributing factors/evidence as
    Common Related Factors

    Impaired transport of oxygen

    Interruption in blood flow
    Mismatch of ventilation with blood flow
    Decreased hemoglobin concentration in blood

    Hypoventilation
    Hypovolemia
    Hypervolemia
    Exchange problems
    Altered affinity of hemoglobin for oxygen

    Without your assessment and information it is really hard to say which is the more important nursing diagnosis.. How low is the B/P and how low does it go?
    Last edit by Esme12 on Apr 28, '13
  8. 0
    For anxiety my book has a defining characteristic of decreased BP/pulse (parasympathetic), and increased for sympathetic. His pulse went to 55, no lower. It was around 55-65 the past 3 days so it's not that low. And the BP was 95/60 during one time, but during the next VS time, it went back up to it's usual. It is usually around 115/69. The patient said this was what it usually looked like.

    His hemoglobin levels are lower than they should be (H/H = 11.1/35.0) but his O2 is 98-100%RA, skin color, sensation, cap refill are all normal.

    So according to Maslow, I would think the priority should be:
    Acute pain
    Nausea
    Imbalanced Nutrtion: less than body requirements
    Last edit by julienurse2b on Apr 28, '13
  9. 0
    I agree...
  10. 0
    Quote from julienurse2b
    amb means as manifested by..

    Even though the pt has anemia, his O2 sat is 98 to 100% on room air. Besides an occasional low pulse and BP, there are no other defining characteristics for ineffective tissue perfusion.
    .
    What's the point of perfusion? Right, to deliver oxygen (and other things).

    Did you know what SpO2 means? Right, it's the percentage of red blood cells carrying oxygen. It is not a measure of anemia and does not change with anemia.
    It is also not the same thing as PaO2, the oxygen carried in the blood as reported by ABG (arterial blood gases).
    FYI, lots of people think an SpO2 of 85% is the same as a PaO2 of 85torr (or mmHg), and they are very wrong. SpO2 of 85% corresponds to an arterial oxygen of about 50 torr (mmHg)-- very bad oxygenation.

    Now consider. What's the difference in the amount of oxygen being delivered to the cells of

    1) a patient with SpO2 of 100% and a hematocrit of forty
    and
    2) a patient with SpO2 100% a hematocrit of twenty?

    Right, the guy with anemia is getting only half the amount of oxygen to his cells, even though both have identical SpO2. So... rethink your assumption that anemia isn't an ineffective thing going on here. SpO2 is only half of the picture.


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