Priotizing nursing diagnoses list

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    I'm working on my first care plan and the instructor is requiring that we have 10 nursing diagnoses, which need to be prioritized into a list using Maslow's hierarchy as our guide (physiologic, safety & security, love and belonging, self-esteem, self-actualization). I've got my 10 diagnoses, but was hoping to get some input on whether I'm prioritizing them in the right order. My patient is a 90yr old female who is in the nursing due to late effect cerebrovascular disease with dominant side (right) hemiplagia.

    1. Risk for falls (hx of falls. My instructor has been placing an emphasis on this to the whole class, which is why its at the top)
    2. Chronic pain (she rates it at 9 out of 0-10, which is why I put it so high in the list)
    3. Feeding self-care deficit (set-up help for meals. Placed as number 3 due to food being a need for survival)
    4. Impaired transfer ability (1 assist to get OOB, independently once in w/c by pulling herself up with handrails. Numbers 4-7 are physiological needs related to activity, I wasn't entirely sure which order they should be in so I put the mobility ones first since immobility affects so many body systems)
    5. Impaired walking (1 assist with walker, needs to take frequent rests due to getting tired)
    6. Impaired bed mobility (1 assist, positions with pillows)
    7. Dressing self-care deficit (needs help with lower body and buttons)
    8. Risk for impaired skin integrity (she moves around a lot and is low risk based on the Braden Scale. I could put this one higher, but figured since she's low risk it wasn't quite as important as immobility and ADLs)
    9. Risk for compromised human dignity (since she needs help with personal hygiene. This is a self-esteem risk, so not as important as the physiologic needs)
    10. Risk for situational low self-esteem (she said that sometimes she feels useless due to her illness and being in the nursing home. My understanding of Maslow puts self-actualization needs last, so that is why this one is on the bottom)

    The care plan isn't due until the 17th (I'm working ahead on it due to having already made up my last clinical day which I will be missing next week - a friend is getting married out of state and I'm one of her bridesmaids), so I have plenty of time to change things if needed. Any input will be welcome!

    (I'm typing this on my phone, which is not the easiest phone to type on, so please forgive any spelling or grammatical errors.)
    Joe V likes this.
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  3. 18 Comments so far...

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    Where are these diagnosis from? Grntea and Esme recommend the Ackley diagnosis book. Also risk for diagnosis are never priority because they are potential problems and not actual problems.

    Also mobility and pain would be my main concerns for this pt
    Esme12 likes this.
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    Are these all NANDA approved nursing diagnoses? Also, when we do our care plans we have to state NANDA diagnoses R/T __________ AEB _______.
    Always refer to your ABC framework, then work your way up Maslow's. As the precious poster stated: risk for DX shouldn't be priority over actual problems. The risk for falls is a safety concern, but ABC and physiological needs must be addressed prior to safety.
    hbrooks likes this.
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    Quote from RED1984
    Are these all NANDA approved nursing diagnoses? Also, when we do our care plans we have to state NANDA diagnoses R/T __________ AEB _______. Always refer to your ABC framework, then work your way up Maslow's. As the precious poster stated: risk for DX shouldn't be priority over actual problems. The risk for falls is a safety concern, but ABC and physiological needs must be addressed prior to safety.
    I am the precious one! Lol
    NutmeggeRN likes this.
  7. 0
    Quote from slinkyheadCNA
    Where are these diagnosis from? Grntea and Esme recommend the Ackley diagnosis book. Also risk for diagnosis are never priority because they are potential problems and not actual problems.

    Also mobility and pain would be my main concerns for this pt
    The book I'm using using is "Nursing Diagnosis, Application to Clinical Practice" by Lynda Carpenito. Its the required book for my program and the book which my nursing diagnoses must come from. The Ackley book is one that my instructor recommended as a resource, but I haven't gotten it yet as one of the nurses at work thought she had one that I can have.

    Pain and mobility are a lot of what I ended up focusing on, too. I'm thinking I might be moving the feeding self-care deficit down the list further...
    Last edit by Jaynie_Marie on Oct 6, '13
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    Quote from RED1984
    Are these all NANDA approved nursing diagnoses? Also, when we do our care plans we have to state NANDA diagnoses R/T __________ AEB _______.
    Always refer to your ABC framework, then work your way up Maslow's. As the precious poster stated: risk for DX shouldn't be priority over actual problems. The risk for falls is a safety concern, but ABC and physiological needs must be addressed prior to safety.
    As far as I am aware, they are all NANDA approved diagnoses.

    When writing up nursing diagoses for the care plan I do need list the R/Ts and AEBs, and I do have them for the diagnoses I listed, I just didn't type them up here because I don't have internet at home and this phone is truly a pain to type on. I am willing to add them to my post if you think its a good idea.

    I agree that I wouldn't put a risk diagnosis before an actual diagnosis (which is one of the reasons my other risk diagnoses are at the bottom of the list), but my instructor has harped on risk for falls a LOT and has said that she expects most of us to have it at the top of the list.
  9. 0
    I couldn't find 4 and 5 in my list of NANDA approved diagnosis. I just find it strange that the Ackley book is only recommended at your school when NANDA recommends it to formulate care plans. At least as far as I know, it's required at most nursing schools.
  10. 3
    I looked up your dxs in my NANDA International book and they're all there, so I'm not sure why some other books don't have them. Weird.

    I don't personally see a problem with your list, but I don't ascribe to the "risks always come last" idea. An actual problem of disturbed energy field won't kill you faster than a fall. The only things

    1. I'd definitely change is the Risk for Impaired Skin Integrity. That's a huge issue for her thanks to her mobility, and it could have big consequences.

    2. If she's immobile, you have some cardiovascular and respiratory risks as well, no?
    Last edit by Stephalump on Oct 6, '13
    Esme12, NutmeggeRN, and lorirn2b like this.
  11. 0
    When I was in school for both LPN and RN, we had to prioritize our NANDA's.

    Airway, breathing, circulation etc and actual problems before potential/risk for problems. An actual problem trumps something that could be/might be a problem.
  12. 2
    Quote from slinkyheadCNA
    Where are these diagnosis from? Grntea and Esme recommend the Ackley diagnosis book. Also risk for diagnosis are never priority because they are potential problems and not actual problems.

    Also mobility and pain would be my main concerns for this pt
    1) The people who say that "risk for" diagnoses are somehow not "real" are dead wrong, and they have only to look at the NANDA-I book to learn that. Just about every one of the Safety diagnoses is a "risk for..." and I am sure that no real nurse would think safety not an actual, ongoing, very real nursing duty and responsibility. The NANDA-I is probably changing the wording for these in the next issue to "Vulnerable to..." in hopes that faculty will stop filling students' heads with that misrepresentation (we all got to vote on that) (I am a member; any RN can be).

    2) ‣ Impaired Transfer Mobility: Limitation in independent movement between two nearby surfaces (Domain 4, Activity/Rest; Class 2: Activity/Exercise)

    3) ‣ Impaired Walking: Limitation of independent movement within the environment on foot (Domain 4, Activity/Rest; Class 2: Activity/Exercise)

    4) I am traveling and do not have my full book with all the defining characteristics (those are the "as evidenced by" bits) and the related to's (causes). Yes, you must identify those from the NANDA-I 012-2014 book to be fully legit, despite the fact that many books (including Ackley and Carpenito, are useful secondary sources. (Get it from Amazon in 2 days and you will never, never regret it. $29, free two-day delivery) If your r/t are out of your own head, be sure they match at least one from the defining characteristics for the diagnosis in the NANDA-I.

    5) If they do, I think the OP has done a beautiful job to start with for this LTC resident (remember, she is not in an acute setting and some of those more serious dx r/t pneumonia, CV, etc. may not really apply to her as they would if she were acutely ill), as her diagnoses are well-prioritized per Maslow, refer specifically to her patient's individually assessed findings, and are literate and well-written to boot, cell phone or not. When you pull up some etiologies for each in addition to the exact defining characteristics, you'll get an A in my book.

    Last edit by GrnTea on Oct 6, '13
    Esme12 and lorirn2b like this.


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