Care plan

[Anthony BSN,RN]

Hi everyone,

I am kind of having trouble trying to prioritize my NANDA-Diagnoses. I have already completed them and I am kind of debating in if to proceed and submit my diagnoses the way I have them prioritize. I would really appreciate any feedback. Here is what I have come up with after finishing up my data clustering.

Ineffective peripheral tissue perfusion related to constriction of blood vessels secondary to diabetes AEB, peripheral edema, temperature of Lower Extremity cold to touch, and delayed capillary refill of 5 seconds Lower Extremity.

On this pt. we have to secure her ABCs, and after that is secured then we can focus on Maslow’s Hierarchy. This diagnoses I chose for my pt. is prioritize first due to circulation. Nurse needs to first prioritize and secure the pt. circulation, since that is an essential need in our everyday life. If the pt. doesn’t have adequate circulation then all of the other systems start to shut off, and more complications arise.

Imbalanced nutrition: more than body requirements related to excessive intake in relation to metabolic need AEB BMI of 52.9, over IBW, and weight of 308.2.

These diagnoses would be second prioritization because the pt. is still able to eat, the only problem is that the pt. will have to reduce her daily intake to control her weight and reduce her BMI. According to Maslow’s Hierarchy this diagnoses belongs to the second stage, which is safety since there is a concern with complications that might present with her health if the pt. does not control her weight.

[RunBabyRN]

I agree with you that the tissue perfusion is the first priority. Now, that said, if you could magically address #2, then #1 would likely be greatly improved. However, in this visit (which is your focus), you can do more to address the tissue perfusion than you can her obesity. You can certainly address the obesity and what changes need to happen to improve it, but circulation takes priority here. Good job! :)

[cayenne06, MSN, CNM]

I would never claim to be an expert in nursing care plans, but I wonder if there is something that is more acutely important to her safety than imbalanced nutrition? Falls, infection risk, airway compromise, risk for injury? Imbalanced nutrition is important, but not emergently life threatening.

[Anthony BSN,RN]

I agree with you that the tissue perfusion is the first priority. Now, that said, if you could magically address #2, then #1 would likely be greatly improved. However, in this visit (which is your focus), you can do more to address the tissue perfusion than you can her obesity. You can certainly address the obesity and what changes need to happen to improve it, but circulation takes priority here. Good job! :)

Thanks for the feedback I really appreciate it. I will sure make that revision :)!

[Anthony BSN,RN]

I would never claim to be an expert in nursing care plans, but I wonder if there is something that is more acutely important to her safety than imbalanced nutrition? Falls, infection risk, airway compromise, risk for injury? Imbalanced nutrition is important, but not emergently life threatening.

After collecting all my data clustering there was a risk for falls since my pt. had a stroke and is paralyzed from her right arm. The only problem is that our instructor don't allow us to use risk for diagnoses for this second care plan. My pt. can't complete her ADLs or IADLs by herself either she needs assistance from one other health care team member. Pt. also has a past dx of COPD, Diabetes, and Hypertension, but doesn't show any signs or symptoms of SOB. She has no crackles, or wheezing, and her pulse oximetry was at 98% normal range.

Thanks for the feedback I really appreciate it :)!!