care plan priority diagnoses

[clearblue3]

Hi all,

So I haven't had a problem putting my diagnoses in order before, but this care plan is really confusing me.

I have a lady who was diagnosed with acute severe divertulitis, she has been NPO and just had surgery for a bowel resection. She is anemic and has HTN. I am trying to put them in order so that I can pick my top 3. My diagnoses are as follows

1. Ineffective Tissue Perfusion r/t decreased production of hemoglobin and RBC's AEB decreased hgb level of 11.1, Hct of 33.4% and RBC of 3.78 secondary to iron deficiency anemia

2. Impaired tissue integrity r/t decreased blood and nutrients to tissue AEB 4/6 cm stage 3 decubitus ulcer on right ischium secondary to reluctance to change position due to pelvic fracture (yes, this lady has an abdominal incision, but my instructor said to pick just one tissue problem)

3. Dysfunctional gastrointestinal motility r/t manipulation of the bowel AEB absence of flatus and bowel sounds

Acute pain r/t inflammation of the bowel and surgical incision AEB patient rates pain as 4-6 on 10 pt scale

Impaired physical mobility r/t pain and prescribed movement restrictions AEB patient states discomfort upon movement secondary to surgical procedure

4. Imbalanced nutrition: less than body requirements r/t decreased ability to ingest food secondary to diverticulitis and colon resection

5. Self-Care deficit, bathing and toileting, r/t pain and weakness secondary to surgical procedure AEB patient states pain and weakness with movement

6. Risk for respiratory infection r/t immobility secondary to abdominal surgery

We were always taught that risks came after actual diagnoses, but does a risk for resp infection really come after her self-care deficit?

So ABCs... I put tissue perfusion first. Then Maslows...this is where I am getting confused...nutrients to skin next with impaired skin integrity? or imbalanced nutrition or decreased gastric motility? I am not even sure what is expected after a bowel resection for gastric motility in terms of when she will have a BM.

I am not really sure what to use for imbalanced nutrition because NANDA says it does not include those that are NPO. but obviously her nutrition is a factor when she has been on clear liquids for several days and then NPO for 2 days. She is not getting any TPN.

Any thoughts would be sooooo much appreciated!!

[jmtndl]

Wow...I'd just make sure she had effective pain med,something for nausea,maybe an IV antihypertensive,an air mattress, and some emotional support!Oh yeah,some anti-thrombolytic measure too.Sounds like you are putting a lot of good thought into this.It is so hard to be a student!Bless you.

[Silverdragon102, BSN]

Moved to the General Nursing Student Discussions forum

[MySonIsAdorable]

How long has she been NPO? Does she have some type of feeding tube?

I do think that respiratory is a risk and they do say that airway comes first so if you can think of some good interventions that might be impressive. You could possibly leave that open and say risk for infection r/t surgical wound. Expected outcome possibly no HAI will not be evident during my shifts?

Honestly they all sound good luck!

[clearblue3]

Thanks for the replies!

She was on clear liquids for 5 days and NPO for 1 during surgery. She doesn't have a feeding tube.

I didn't put my resp. diagnosis at the top since it is a risk diagnosis and not something that is actually occuring. Same with a risk for infection r/t surgical wound. Since I could only pick one dx for integumentary I picked the Impaired Tissue Integrity r/t pressure ulcer over a risk dx.

What is HAI?

Care plans are just so tricky! :-)

Thanks :-)

[nurseprnRN, BSN, RN]

see, the idea that "risk for.." automatically is lower down the importance chain is an assumption a lot of students make when their faculty tell them to use actual diagnoses first. "risk for.." is no less important but a lot of students can't see the forest for the trees so they start pulling "risk fors" out of the air because they can't think of how to justify anything else. faculty want to push you into looking for actual, clear and present nursing diagnoses in part because they want to know how good your assessment skills are and, having assessed, what you're going to do about your findings when you figure out what your plan is for looking after this patient's interests and needs.

however, some "risk fors" are pretty high-priority. i think what you want to do is demonstrate to your faculty that you recognize their hopes for you, that you will, in fact, identify actual problems, and not then just tack on a couple of half-baked "risk fors" at the end. this lady has some significant risks, and if you give them good thought and attention, it won't matter where you put them.

this is where you make your arguments for your priorities. if faculty wants them listed later, put them later; just don't take from this that faculty think they are insignificant. they aren't, and they don't, and they want to know why you don't, either. nice job so far.

[clearblue3]

Thanks GrnTea!

Great advice!! That is good to know....yes, we have always been told that risks are never as important, but as I did this care plan it became apparent that that must not always be the case! ie. her risk for infection is huge...respiratory, surgical incision, pressure ulcer. Preventing her infections is a big priority! I will keep all of that in mind when I am in the "real world." :-) I am just not a fan of all of the rules for prioritizing care plan diagnoses. Yes, ABC's makes sense, but I am just not a big fan of maslow right now because I just don't think that should be a hard rule that physiological should always come before psychosocial. Would constipation for a day or two really come before 10/10 pain? Or a major safety issue? I sure wouldn't think so. It is much easier to just use common sense then some of these rules they give us! :-) Well, thanks for you thoughts! I appreciate it!