Help! Nanda nursing problems in priority order?

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Hi! This is my first time posting!

I was given the assignment to put the following nursing diagnosis based on a mock patient they gave us:

Activity Intolerance AEB pt lying very still and rigid position, grimaces anytime someone moves her, And when asked to turn to her side, she states that she is too weak.

Acute confusion AEB slurred speech and gives inappropriate answers to staff and family members related to person/place/time

Deficient Fluid Volume AEB serum osmolality elevated, urine is concentrated and output has been 20 ml/hr for 4 hours, temp 103.4 rectally, pulse 124 and weak, BP 86/38, dry skin, decreased skin turgor, dry and sticky mucous membranes.

Hyperthermia AEB temp of 103.4 rectally

Nausea AEB states she is sick to her stomach, sometimes gags but only brings up small amounts of clear fluid.

Acute pain AEB pt rates her pain as 9- in left leg and entire abd region.

Ineffective protection AEB pt will not cough or deep breathe nor turn or do post-op leg exercises.

Disturbed sleep pattern AEB states she is drowsy, naps about 20 mins at a time, states she can't stay asleep, is restless and irritable.

We only have to list the top 3 priorities. The order I put them in was 1. Deficient fluid volume, 2. Hyperthermia, 3. Acute pain

I have to list the rationale for why these are the most important and I'm coming up blank! Mostly because I'm unsure these are highest priorities!

Thanks in advance for your help :)

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I like those but I would FVD since that could be causing the other two issues.

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Oops meant to say FVD 1st

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Yeah that's what I thought and it's most life threatening. Also, I'm unsure about the third one... Is pain important than any of the others? Or maybe disturbed sleep is more important?

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I would keep pain as number three. They say pain is the fifth vital sign, and perhaps if that could be controlled, her sleep would improve.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

We are happy to help with home work.....but I like to know what you think first so that we can work it out for it to make sense to you...so that it makes sense for you you will be using this stuff for your entire career......usually you think about what can hurt them first. What semester are you?

ABC......airway, breathing, circulation.

Look at Maslows......the bottom of the pyramid being the most important.

maslows_hierarchy_of_needs-4-300x290.jpghttp://www.maslowshierarchyofneeds.net/maslows-love-and-belonging-needs/

The triangular visual aid Maslow created to explain his theory,which he coined Hierarchy of Needs, depicts the levels or steps of human, psychological and physical needs human beings have to ascend to reach self-actualization. Going from the bottom up:

  1. Basic Needs or Physiological Needs - these are somewhat obvious and necessary for basic human survival. Without food,air, drink, warmth and sleep, the human body cannot continue to function.
  2. Safety Needs - Once physical needs are somewhat satisfied, focus on safety needs take precedence and dominate our behavior. These needs being satisfied quell our need for an orderly predictable world where unfairness and inconsistency are under control.
  3. Belongingness and the Need for Love - Once basic and safety needs are met, human needs become social and involve a need for acceptance and to love and be loved. If these elements are absent, social anxiety and depression can arise.
  4. Esteem Needs - This level is is attained when individuals feel comfortable with what they have accomplished from a success and status standpoint.
  5. Cognitive Needs - At this point, we feel a need to increase our intelligence and we chase knowledge to gain a better understanding of the world around us. We now feel a need to explore and desire new experiences.
  6. Aesthetic Needs - With the previous needs satisfied, we now find we need to refresh ourselves with the presence of beauty, nature, art, music and the other aesthetically beautiful things the world has to offer. This leads to a beautiful feeling of intimacy and oneness with nature and everything beautiful.
  7. Self-actualization - This is our instinctual need as humans to make the most of our abilities and to strive to be the best we can be. Quoting Maslow "What a man can be, he must be." It is also at this level that individuals experience extraordinary moments called Peak Experiences which include transpersonal and ecstatic states tinged with themes of euphoria, harmonization and interconnectedness.
  8. Transcendence - Having personally self-actualized, there is a desire to help others self-actualize. In doing so, we connect with something beyond the ego and we experience states beyond normal human consciousness and take things to another level of being.

http://www.consciousaging.com/Transpersonal Psychology/Conscious Aging - Maslow's Hierarchy of Needs.aspx

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I'm starting my second semester on Monday and I'm I'm a two year program right now. I'm doing a seminar review right now since I took off last semester. I understand Maslow's but our instructors love when we debate over this stuff so I know a lot of them will have different opinions.

Thanks so much for the help :)

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Hi! This is my first time posting!

I was given the assignment to put the following nursing diagnosis based on a mock patient they gave us:

Activity Intolerance AEB pt lying very still and rigid position, grimaces anytime someone moves her, And when asked to turn to her side, she states that she is too weak.

Acute confusion AEB slurred speech and gives inappropriate answers to staff and family members related to person/place/time

Deficient Fluid Volume AEB serum osmolality elevated, urine is concentrated and output has been 20 ml/hr for 4 hours, temp 103.4 rectally, pulse 124 and weak, BP 86/38, dry skin, decreased skin turgor, dry and sticky mucous membranes.

Hyperthermia AEB temp of 103.4 rectally

Nausea AEB states she is sick to her stomach, sometimes gags but only brings up small amounts of clear fluid.

Acute pain AEB pt rates her pain as 9- in left leg and entire abd region.

Ineffective protection AEB pt will not cough or deep breathe nor turn or do post-op leg exercises.

Disturbed sleep pattern AEB states she is drowsy, naps about 20 mins at a time, states she can't stay asleep, is restless and irritable.

We only have to list the top 3 priorities. The order I put them in was 1. Deficient fluid volume, 2. Hyperthermia, 3. Acute pain

I have to list the rationale for why these are the most important and I'm coming up blank! Mostly because I'm unsure these are highest priorities!

Thanks in advance for your help :)

Yes well...you said it was an assignment......

Remember ....your nursing diagnosis comes from patient assessment. Maslows is really all about what will kill them first. For the rest of your career you will be making decisions like this using this information...it just won't be labeled.

Do you see the patient who wants their water pitcher filled, the patient 2 days post op who is requesting his pain med right on time or the patient for GB complaining of sudden sharp chest pain that has been NPO for the last 8 hours. ...and doc so and so wants to ask about tomorrows OR schedule. They ALL want you NOW ....who do you see first? These scenarios happen every day, all the time .....you will need to know what to do nest. These exercises help lead you to the critical thinking skills that you will develop for the care of your patients.

Now......

You have a confused patient with a decreased LOC.......with a concentrated urine output of 20cc/hr for 4 hours (30cc/hr is indicative of end organ perfusion) febrile with a temp of 103.4, with tachycardia and a weak HR of 124, hypotension with a B/P of 86/38. Skin is dry, turgor poor, dry and sticky mucous membrane and a serum osmolality elevated,

If this was your patient and you got report....you go in and see them.....what about this picture would concern you? what will alarm you the most that you need to care for first while other stuff waits.

You have decided....

We only have to list the top 3 priorities. The order I put them in was 1. Deficient fluid volume, 2. Hyperthermia, 3. Acute pain
Now what evidence do you have that place these in that order and why?

YOu start....what about this assessment make defecient volume you main concern.....

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