Nursing Diagnosis in PRIORITY ORDER??? - page 2

by emlam

9,334 Views | 17 Comments

Hi! This is my first time posting and having an actual nursing diagnoses assignment and I keep doubting my answers and just want to know if there is anything I should improve on. I have to do 4-5 psychosocial/medical and learning... Read More


  1. 1
    Anytime. Just remember...actual problems need R/ T and AEB...info, labs, objective and subjective data that PROVES the nursing dx. And be specific with the AEB (lab value, temp, vitals, etc).

    Risk for nursing diagnosis do have a R/T but no AEB...because..if there is evidence of the diagnosis it is no longer a risk but an actual problem.

    Now, don't forget on Monday your patient might be AT RISK for ineffective airway clearance...because there are no s/s to use as evidence that they do...but on Tuesday they may have evidence of that diagnosis (low o2 sats, adventagious lung sounds, etc)...so it then becomes an actual problem.
    emlam likes this.
  2. 0
    Do I have to use numbers for weight loss? I have two Actual problems that have AEB weight loss
    1. Altered nutrition less than body requirements R/T ineffective feeding pattern AEB failure to gain weight.
    2. Deficient fluid volume R/T vomiting AEB decreased urine output, weakness, and sudden weight loss.
  3. 0
    If they were my diagnosis I'd use the amount of weight lost. BUT..babies tend to lose weight in their first few days and its not uncommon. Is your patient's weight loss a concern to the doctor or is it the normal weight they expect babies to lose? If its the norm I'd go with RISK for with that dx.

    Don't quote me but i think they say that 5% of weight lost in the first few days is common for average weight healthy newborns who are bottle fed and a little higher for breastfed babies.

    Judging from your AEB on the fluid volume I'd have to say this baby does have a greater than average weight loss. So yes, use the % of body weight lost from birth.
  4. 0
    With neonates some of your AEB will be different than in adults. Such as weight loss. They lose weight first, then begin to gain. So you may have to include parameters and specifics. I would careplan for hypothermia. But just as you can't rely on touch of feet and hands for hyperthermia you will need specifics. Think about the the physiological changes the newborn is going through as they transition to extra-uterine life. Lots of "potential for" diagnoses. Are they breast fed? Bottle fed? Been circumcised? Anything in maternal history? Good luck!
  5. 1
    Quote from emlam
    Hi! This is my first time posting and having an actual nursing diagnoses assignment and I keep doubting my answers and just want to know if there is anything I should improve on. I have to do 4-5 psychosocial/medical and learning needs. This is my Ob rotation and I am writing diagnoses for the baby. Then I have to list them in order by PRIORITY (#1-5). Thanks in advance for your comments!

    Psychosocial:

    1) Risk for ineffective airway clearance R/T excess mucus production E/B dyspnea...etc

    2) Risk for altered nutrition less than body requirements R/T possible ineffective feeding pattern E/B failure to gain weight

    3) Risk for hyperthermia R/T increased bundling... E/B increased body temperature greater than 100F

    4) Risk for infection R/T immature immune system E/B respiratory symptoms such as apnea, tachypnea, grunting, or retracting

    5) Risk for diaper rash R/T infrequent diaper changes E/B skin inflammation appears redness, scaling, blisters, or papules

    Learning Needs

    1) Knowledge def R/t ineffective airway clearance E/B pt. statement "I will put the bulb syringe in my baby's nose and then compress to suction"

    2) KD R/T to infant feeding pattern E/B pt. statement "I don't kow what times to feed my baby at"

    3) KD R/T safe sleep E/B pt. statement "My baby has a favorite blanket that I let her sleep with in her crib"

    4) KD R/T car seat safety E/B pt. statement "I will place my baby in the caarseat in the front passenger seat so she is next to me"

    5) KD R/T infant care E/B pt. statement "I don't know who to go to whne I need help, it is only my husband and I"
    Airway breathing circ, after that prioritize by maslows higherarchy of needs.

    Sent from my iPhone using allnurses.com
    Meriwhen likes this.
  6. 0
    HI CT Pixie, I just took an exam and the question asked for the Priority nursing diagnosis for a HIV pt. with oral candidias...
    A. Risk for infection
    B. Disturbed body image
    C. Risk for imbalanced nutrition
    D. Risk for skin impairment
    I answered the question based on PRIORITY, which was what was actually happening at the moment (answer chosen: Disturbed body image, original answer: Risk for infection) , than what the pt. will be at Risk For. I keep doubting myself, not knowing what my teacher really was asking.
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    The thing about exams is although my teachers would say actual problems before risk fors...sometimes the risk for is of more importance than 'the problem'. Such as with this question.

    Ok, so the pt has oral candidias, what does that mean..what happens? Hint..can't eat too well when your corners of your mouth/inside your mouth, mucous membranes are a mess, etc. Sooo, what would that put the patient at risk for?

    with this one, I'd get rid of disturbed body image b/c even though its worded as a problem, its not really the biggest nursing priority. To me the biggest priority would be the risk for imbalanced nutrition r/t pain, discomfort the pt has in his/her mouth. without proper nutrition, the pt can't really fight off any new infection nor heal, repair or maintain skin integrity. If I were answering this questions I'd go with risk for imbalanced nutrition. I can't guarantee its correct, but that's where I was lead.
  8. 0
    Thank you CT Pixie


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