Priority Nursing Diagnoses Help

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    hi everyone! i'm in my second semester of clinical rotation now, and need some help with my care plan for this week. i have a few nursing diagnoses that i believe are priority, but i need to narrow it down to three for my actual care plan. i need help trying to order them by priority.

    my pt has a pmh of chf, htn, and dm type 2. he came to the hospital s/p fall and has a uti. he has a high level of confusion due to the head injury and uti. he also had a retro-peritoneal bleed and is on isolation for mrsa.

    here's some of the nursing diagnoses i can up with: (i just have the first part of the diagnosis, i am going to piece everything together in the end.)

    1. decreased cardiac output [he has the history of chf, he has an s3 present, tachycardia, htn, low spo2 (92%). his ekg showed he has non-specific st and t wave elevations. troponin was normal.]

    2. altered mental status [he was also being combative - should i maybe include that he's a risk to injure others? not a priority, but could be used in my concept map.]

    3. altered tissue perfusion [he has numbness/tingling in both feet, black discoloration from diabetes, also has a pressure ulcer (but would that be tissue integrity rather than perfusion?) ]

    4. infection [uti and mrsa]

    5. pain [i'm not sure if i should include this as a priority because his pain was a 2/10. but to me, all pain is priority. i'm just not sure if my professor would agree.]

    i wanted to include ineffective breathing pattern possibly.. but i'm not sure. his spo2 was 92%, respirations were labored. crackles in both bases of lungs due to chf.. and diminished breath sounds. he was supposed to be on 2 l by nc, but he kept ripping it off when he became combative with the staff.

    i just need help organizing everything! i have a lot to include here.

    thanks everyone in advance!

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    Is this the order that you have decided is priority? I don't want to give you the answers or too many hints. :P Want to see where you are at? What are your 3 priority nursing diagnoses and what the order of those?

    Some folks will say follow the ABCs or follow the ABCs then do maslow's needs.

    A-Airway, what conditions does he have that threat the airway?
    B-Breathing, what conditions does he have that threats breathing?
    C-Circulation, what conditions does he have that threats circulation?
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    lessee here.

    1. decreased cardiac output [he has the history of chf, he has an s3 present, tachycardia, htn, low spo2 (92%). his ekg showed he has non-specific st and t wave elevations. troponin was normal.] what is your evidence for a present, right-now decreased cardiac output? decreased spo2 doesn't cause that or define it, and he doesn't have an acute infarct, so...? what's your thought process here? i wouldn't be able to say definitively that this is a priority unless you tell me why it's a problem-- data first, diagnosis and treatment plan second.

    2. altered mental status [he was also being combative - should i maybe include that he's a risk to injure others? not a priority, but could be used in my concept map.]
    rather than just say, "altered mental status," you could think about why this matters to you as his nurse. think a little more broadly.

    3. altered tissue perfusion [he has numbness/tingling in both feet, black discoloration from diabetes, also has a pressure ulcer (but would that be tissue integrity rather than perfusion?) ]
    the numbness and tingling is diabetic (now you tell us!) neuropathy; if there are really blackened necrotic areas and an open wound, that's a serious tissue integrity problem related to decreased perfusion. do you have data on capillary fill, peripheral pulses, temp, hair distribution, nails?

    4. infection [uti and mrsa]
    "infection" is not a nursing diagnosis. where are you going with this?

    5. pain [i'm not sure if i should include this as a priority because his pain was a 2/10. but to me, all pain is priority. i'm just not sure if my professor would agree.]
    again, with no evidence other than the 2/10, i can't tell whether it is or not.

    so, i can't really speculate on what is most important to this man right now, because i don't have a real good picture of him in my mind due to lack of assessment data from you. people always quote maslow or erickson, and the abcs, and those are useful, but they are tools, not requirements. so, explain to us what you think his problems are and how you know he has them based on your assessment data points-- as you clarify that thinking in your mind, you may discover your answers on priority-setting care.
  6. 1
    duplicate post
    Last edit by GrnTea on Apr 25, '12 : Reason: , ? reason.... gremlins in the system again?
    Esme12 likes this.
  7. 0
    Quote from jen2010
    hi everyone! i'm in my second semester of clinical rotation now, and need some help with my care plan for this week. i have a few nursing diagnoses that i believe are priority, but i need to narrow it down to three for my actual care plan. i need help trying to order them by priority.

    my pt has a pmh of chf, htn, and dm type 2. he came to the hospital s/p fall and has a uti. he has a high level of confusion due to the head injury and uti. he also had a retro-peritoneal bleed and is on isolation for mrsa.

    here's some of the nursing diagnoses i can up with: (i just have the first part of the diagnosis, i am going to piece everything together in the end.)

    1. decreased cardiac output [he has the history of chf, he has an s3 present, tachycardia, htn, low spo2 (92%). his ekg showed he has non-specific st and t wave elevations. troponin was normal.] an s3 heart sound is associated with chf (caused by over-expansion of the ventricle during the heart's filling phase). tachycardia is associated with infection, pain, etc. he has a pmh of htn, so the htn isn't surprising. the sat could be low due to the chf, the infection, the decreased h&h from the retro-peritoneal bleed, etc. the information you've given isn't conclusive enough to arrive at the diagnosis of decreased cardiac output. you need more information to arrive at this conclusion.

    2. altered mental status [he was also being combative - should i maybe include that he's a risk to injure others? not a priority, but could be used in my concept map.] sure, this patient poses a risk for injury to others, but what about himself? think in a broader scope. he does have altered mental status, but he also poses a risk for injury to himself.

    3. altered tissue perfusion [he has numbness/tingling in both feet, black discoloration from diabetes, also has a pressure ulcer (but would that be tissue integrity rather than perfusion?) ] the numbness and tingling could be associated with the diabetes. the pressure ulcer could be a result of decreased perfusion, as grntea said. also, as grntea said, you need data about capillary refill, peripheral pulses, extremity temp, etc.

    4. infection [uti and mrsa] infection isn't a nursing diagnoses. perhaps you could go with risk for infection r/t impaired skin integrity secondary to decubitus ulcer.

    5. pain [i'm not sure if i should include this as a priority because his pain was a 2/10. but to me, all pain is priority. i'm just not sure if my professor would agree.] what pain level did the patient indicate was acceptable? pain that is a 2/10 doesn't really take priority when the sat is a little low, and there are other, more important, interventions. if the pain was an 8 or 9, then i would put more emphasis on it.

    i wanted to include ineffective breathing pattern possibly.. but i'm not sure. his spo2 was 92%, respirations were labored. crackles in both bases of lungs due to chf.. and diminished breath sounds. he was supposed to be on 2 l by nc, but he kept ripping it off when he became combative with the staff. i would also consider impaired gas exchange. the sat is low (more indicative of impaired gas exchange). the crackles may also support ineffective gas exchange. ineffective breathing pattern does work with the increased respiratory rate and diminished breath sounds.

    i just need help organizing everything! i have a lot to include here.

    thanks everyone in advance!

    you have some good ideas, and you're way of thinking isn't entirely bad. you do, however, need more evidence, and a more thorough assessment, before you start making some of these conclusions about your patient. as grntea said, patient data first, then nursing diagnoses.
  8. 1
    "quote jen........here's some of the nursing diagnoses i can up with: (i just have the first part of the diagnosis, i am going to piece everything together in the end.)"
    1. decreased cardiac output [he has the history of chf, he has an s3 present, tachycardia, htn, low spo2 (92%). his ekg showed he has non-specific st and t wave elevations. troponin was normal.]

    ok you know that he has chf. what is chf? i know congestive heart failure but what exactly chf. does this patient have right or left heart failure? is this patients chf from a weakened heart muscle from previous mi's or some form of cardiomyopathy caused by long with standing htn and diabetes or valvular disease? you need to know this before determining if this is what is causing his decreased cardiac output. do you know what a s3 is? why is that significant...... or is it significant in the presence of chf? let me google that for you congestive heart failure prognosis, symptoms, stages, causes, treatment - emedicinehealth

    tachycardia. why does he have tachycardia? what is the origin of the tachycardia? is he tachycardic from being agitated from his confusion due to his head injury? what exactly is his head injury....epidural hematoma? subdural hematoma? diffuse axonal injury? (severe concussion) was this patient alert as a baseline prior to injury? let me google that for you (i use this as an engine it's fun and gives great results)

    or is the tachycardia volume related? could it be due to blood loss from the retroperitoneal bleed? what is his h&h? what is his retroperitoneal bleed come from/caused by? a pelvic fracture?

    an o2 sat of 92% maybe normal for this patient unless he is in chf as evidenced by.......what? crackles? sob? jvd? lower extremity edema? where are his vital signs. what is this patients rr rate? is he in distress?

    or is the tachycardia caused by pain.......

    2. altered mental status [he was also being combative - should i maybe include that he's a risk to injure others? not a priority, but could be used in my concept map.]

    again why is this patient altered? what is this patient pathophysiology of his injury? is this patients safety at risk? due to his already history of a severe fall and his confusion/agitation? is his confusion from head trauma? let me google that for you

    or could his confusion be from hypoxia? (unlikely with an o2 sat of 92% but it is worth investigating. is this patients safety at risk because of his agitation and confusion. would this be a priority with this patients present signs and symptoms? is this patients tissue integrity at risk due to possible further falls due to his confusion?

    or could the confusion be caused by infection in the elderly? is this patient elderly?

    3. altered tissue perfusion [he has numbness/tingling in both feet, black discoloration from diabetes, also has a pressure ulcer (but would that be tissue integrity rather than perfusion?) ]

    why does this patient have numbness? is numbness always caused by poor circulation (perfusion) or could it be caused nerve damage (neuropathy?)diabetic neuropathy - mayoclinic.com what is the black discoloration of this patients legs caused by? is this tissue perfusion/circulation or was it caused by pressure from lying on the floor for a period of time.....undiscovered for an extended period of time after his fall? (a common presentation in the elderly)

    which brings up ....what are the patients labs? what is his h&h? what are his electrolytes, bun creat? what have his glucoses been? what cause this patient fall at home? what was his presentation to the ed? was it glucose related? what might you need to think of to plan for this patients discharge/placement? is his family involved? does he live alone?

    4. infection [uti and mrsa]

    where is the mrsa? is the patient being treated? is this a priority right now in the care of this patient?

    5. pain [i'm not sure if i should include this as a priority because his pain was a 2/10. but to me, all pain is priority. i'm just not sure if my professor would agree.]

    pain needs to always be addressed....but is it a high priority for this patient right now with his pain level a 2? which indicates his pain is pretty well controlled. remember priority is based on important news first. the basic abc's......if the ain't breathin they be leaving (to heaven that is.....)
    i wanted to include ineffective breathing pattern possibly.. but i'm not sure. his spo2 was 92%, respirations were labored. crackles in both bases of lungs due to chf.. and diminished breath sounds. he was supposed to be on 2 l by nc, but he kept ripping it off when he became combative with the staff.

    is his breathing pattern all that ineffective? or.........are his lungs so full of fluid that he can't get enough air? what would this patient need in order to breathe easier and possibly decrease his confusion/agitation? if this patient can't breathe would that make this a priority?

    think if it was your family member......what would be important to you to be cared for first? which is causing the most risk to the patients life

    look at maslow's to tell you which priority precedes the next.


    the greatest priority is at the bottom (the largest platform)and work your way up

    let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first. you need to know the pathophysiology of your disease process. you need to assess your patient, collect data then find a diagnosis. let the patient data drive the diagnosis. what is your assessment? how many days post op? is the patient having pain? are they having difficulty with adls? what teaching do they need? what do you want to push fluids? what does the patient say? what are the labs? what does the patient need? what is the most important to them now?

    the medical diagnosis is the disease itself. it is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

    care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. it is trying to teach you how to think like a nurse. think of them as a recipe to caring for your patient. your plan of how you are going to care for them.

    from a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

    daytonite...........every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the nanda taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. you need to have access to these books when you are working on care plans. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

    don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics.

    here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:
    1. assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
    3. planning (write measurable goals/outcomes and nursing interventions)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met)

    a dear an contributor daytonite always had the best advice.......check out this link.
    http://allnurses.com/nursing-student...is-290260.html

    you need a good care plan book. i prefer gulanick: nursing care plans, 7th edition. they have an online care plan constructor. it used to be free but they caught on so now you need to buy the book to use the constructor.

    care plans must be chosen from the "approved" script....nanda. i think the biggest mistake students make is that the need to let what the patient says, does and feels (the assessment) dictate what you do next. not the medical diagnosis and try to fit the patient into diagnosis. some other helpful links.

    nursing care plan | nursing crib
    nursing care plan
    nursing resources - care plans
    nursing care plans, care maps and nursing diagnosis
    http://www.delmarlearning.com/compan.../apps/appa.pdf
    understanding the essentials of critical care nursing
    Last edit by Esme12 on Apr 26, '12 : Reason: sp
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