Confused with coming up with an appropriate nursing diagnosis for concept map

[krissy220]

I was assigned a concept map of a client care plan from my clinical rounds. I'm struggling with coming up with an appropriate 3-part nursing diagnosis and an at-risk for diagnosis. My client was admitted to the E.D. with hypoxia signs and symptoms. So her priority problem upon admission was the acute respiratory failure as well as acute kidney disorder, and sepsis. She has a long list of chronic disorders, and impaired mobility and weakness as well. Her breathing has since been stabilized and transferred to the intensive care unit. Her lab values still show leukocytosis, and she is currently on IV antibiotics. I wasn't sure what to use as my 3-part nursing diagnosis as well as my risk-for, as her airway is stabilized. I'm thinking the septicemia or her acute kidney disease is the primary problem as of now, and ineffective airway clearance is a risk for diagnosis. If anyone is interested in sharing their input on this matter, I'd be more than appreciative!

Thanks!

Krissy

[NotMyProblem MSN, ASN, BSN, MSN, LPN, RN]

Why wouldn't you use the respiratory condition? Being stabilized doesn't mean that one is not at risk for a recurrence, right? Especially if that is one of the MAJOR reasons for presenting to the ER in the first place.

[krissy220]

Yes, I was thinking along those lines as well. I just wasn't sure If I should make that a risk for diagnosis or the actual diagnosis, since the patient's breathing was already stabilized when performing my assessments.