Diagnosis Priority

[momandsn]

I have a question in prioritizing my nursing diagnoses. Would risk for aspiration be a higher priority than Impaired Gas Exchange? I am thinking yes, but I tend to overthink myself. Thanks in advance for your replies. My patient did not have an actual diagnosis of Dysphagia, but we had speech therapy come to test him because he kept getting choked when he tried to eat or drink. I didn't get the results of this before my day ended. It seemed to be worse when he drank water. I have impaired gas exchange listed as well because he was alternated q 4 hours from face mask at 100% to cpap.He had orders for intermittant aerosol with albuterol 2.5 mg. His cbc was as follows--rbc 4, hgb 11.2, hct 35.8, mchc 31.3, rdw 16, polys 77, lymph 13, and mono 9. He was also very sedated and wasn't really alert all day. He had been receiving Haldol 4 mg ivp prn agitation and Zanax .25 mg po bid which would explain why he was so groggy, but wouldn't these add to his respiratory problems? I couldn't get him to even attempt to do the incentive spirometer because he wasn't conscious enough to close his mouth on the tube. He was in for redo sternotomy, mvr, & avb. His ef was 53%. He was mrsa + so he was on contact precautions. He was on telemetry and was going from NSR to A-fib. This didnt happen during my day of care tho, he stayed in NSR. He had an external pacemaker. Pacer settings : mode-dddr; rate 80; sensitivity 0.5 atrial, 2.5 ventricular; output 20 atrial, 10 ventricular. The pacemaker rate was decreased to 40 on my day of care. He had TED hose, Foley cath, RIJ, picc to left upper arm, and his mediastinal incision-which is where he tested + for MRSA- was open to room air. He was also diabetic and got Lantus 30 units q day at 9 am, and other doses based on his blood sugar- which was 140 when I checked it so he didnt have to get any insulin at that time.

My diagnosis so far are:

risk for Aspiration(or ineffective Airway Clearance) r/t ineffective cough(??)

Impaired Gas Exchange r/t inadequate ventilation, diminished o2 carrying capacity

risk for decreased Cardiac Output r/t decreased preload, alterations in electrical conduction

Acute Pain r/t mediastinal incision

Imbalanced Nutrition less than body requirements r/t decreased oral intake

Impaired Skin Integrity r/t surgical incision

ineffective Breathing Pattern r/t respiratory center depression, decreased lung expansion(lung sounds were diminished)

Ineffective Role Performance r/t recuperative process

Fear/Anxiety-moderate- r/t situational crises

These are not in order yet, but the main ones I am concerned about is which would come first on the risk for aspiration and Impaired Gas Exchange. Again thanks in advance for any input....

[Daytonite, BSN, RN]

would risk for aspiration be a higher priority than impaired gas exchange?

no.

impaired gas exchange

would be sequenced before

risk for aspiration

. the

impaired gas exchange

is an actual nursing problem that already exists with signs and symptoms that you found during your assessment.

impaired gas exchange

is a problem that has to do with oxygenation. on maslow's hierarchy of needs the need for oxygenation is at the top of the list in priority. without oxygen the cells of the brain will die in 4-7 minutes. a

risk for aspiration

is merely something that you are concerned may happen--an anticipated problem so it can never take priority to actual problems.

the sequencing for your diagnoses should be:

1. impaired gas exchange r/t inadequate ventilation, diminished o2 carrying capacity
   
   • "inadequate ventilation" (your related factor) is the nursing problem of ineffective breathing pattern and i wouldn't use another nursing diagnosis as a related factor for this nursing diagnosis. your related factor must explain how the two gasses (o2 and co2) have come to be at an excess or a deficit (the definition of this diagnosis). "ventilation perfusion imbalance" will work just fine.
     
   • diagnosis: impaired gas exchange r/t ventilation perfusion imbalance
     

[*]decreased cardiac output r/t altered heart rate

[*]ineffective breathing pattern r/t respiratory center depression, decreased lung expansion(lung sounds were diminished)

[*]imbalanced nutrition less than body requirements r/t decreased oral intake

[*]acute pain r/t mediastinal incision

[*]impaired skin integrity r/t surgical incision

• this is the wrong diagnosis. it should be impaired tissue integrity. if you read the definition of these two diagnoses you will find that impaired skin integrity only covers wounds that are as deep as the dermis and epidermis. impaired tissue integrity covers everything deeper.
  

[*]fear/anxiety-moderate- r/t situational crises

• fear and anxiety are 2 different diagnoses. read the definitions of both carefully and go over the patient's symptoms before diagnosing one or the other.
  

[*]ineffective role performance r/t recuperative process

[*]risk for aspiration(or ineffective airway clearance) r/t ineffective cough(??)

• your risk factor, ineffective cough, is wrong. it is the inability to detect secretions in the throat (absence of a gag reflex) that is the risk. that is what makes is possible for the patient to aspirate their secretions and food. an ineffective cough results in secretions remaining in the lung and the patient at risk for getting pneumonia.
  

[*]risk for decreased cardiac output r/t decreased preload, alterations in electrical conduction

• this is not an official nanda diagnosis and it is a wrong diagnosis
  
• your patient already has decreased cardiac output. they have cardiac arrhythmias (atrial fibrillation) and has a pacemaker for some reason.
  

[VickyRN, MSN, DNP, RN]

Awesome post, Daytonite!

[momandsn]

Thank you Daytonite, as usual you really help me with rationalization. You're a lifesaver in more ways than one!!