I have trouble prioritizing nursing diagnoses.. This is for a case study in med/surg class. My patient has multiple medical history but she was admitted for anemia, acute exacerbation of chronic heart failure, and GI bleed. Past medical history include chronic diastolic heart failure with hx of PPM, CAD, HTN, HLD, hypothyroidism, CKD, and multiple GI problems including hx of rectal CA with transanal resection. There was little bleeding when she was admitted but she stated that it has lasted for last 2 weeks, and she had pantoprazole drip, Lasix IVP, and blood transfusion.
She is A/O x 4, standby assist, has dependent edema 1+ in BLE, weak peripheral pulses in BLE, and has a F/C. Her labs are WNL except for low H/H levels, low RBCs, high BNP, and high BUN/Cr. Her lipid panel shows slightly high LDL and low HDL but otherwise normal. Troponins are negative. Chest X-ray shows moderate pulmonary congestion. The bleeding has stopped when I assessed her 4 days later and it seems to me that controlling her fluid retention seems number one because she complained of shortness of breath and weakness upon exertion x 2 weeks and she had a weight gain of 20 lbs but has since lost 6 lbs. The main plan of care is to continue diuresis. My focus is on the cardiovascular system.
I have ordered the nursing diagnoses in the following order (there are more but at least one physiological, one psychosocial, and one educational):
1. Excess fluid volume R/T compromised circulatory mechanism secondary to chronic diastolic heart failure AEB orthopnea, shortness of breath, dependent edema in bilateral lower extremities, decreased peripheral pulses in lower extremities, weight gain, pulmonary congestion, and decreased H/H levels
2. Ineffective tissue perfusion R/T compromised circulatory system and decreased hemoglobin concentration in the blood secondary to anemia, gastrointestinal bleeding and chronic heart failure AEB dyspnea, dependent edema on bilateral lower extremities, weak peripheral pulses at lower extremities, rough and hard skin in lower extremities.
3. Ineffective breathing pattern R/T compromised circulatory system secondary to pulmonary congestion AEB shortness of breath, orthopnea, pulmonary congestion, dyspnea upon exertion.
4. Decreased cardiac output R/T altered preload, afterload, and contractility of the heart secondary to chronic heart failure AEB shortness of breath, orthopnea, fatigue, weight gain, dependent edema in bilateral lower extremities, decreased peripheral pulses in the lower extremities, and diminished breath sounds in the bases of the lungs
5. Readiness for enhanced coping
6. Readiness for enhanced knowledge
I know that you should always prioritize diagnoses that would have the most impact on the patient (airway, breathing, circulation) but in this case it's controlled (patient can maintain own airway, only has dyspnea upon exertion, and has a PPM and HF is controlled by meds). Should I re-prioritize?
