need urgent help for this... pls..

[kaye_d_simple]

I really need an urgent help for this. I dont know if how will I rank this diagnoses and give justification for each one.. pls help me.. thanks..

1.Impaired gas exchange related to hypoventilation as evidenced by dyspnea

2.Ineffective Tissue Perfusion related to impaired transport of oxygen across alveolar and/or capillary membrane as evidenced by dyspnea

3.Acute pain secondary to slipped disk

4.Activity intolerance related to imbalance between oxygen supply and demand

5.Impaired walking secondary to slipped disk

6.Ineffective airway clearance realated to mucuc production

7.Risk for fall related to presence of acute illness (hypertension)

:nuke::redbeathe

[Valerie Salva, BSN, RN]

If you have a care plan book, you can do it.

[Dalla]

Remember the ABCs, airway, breathing, and circulation are the most important. Pain and risks are secondary.

[Daytonite, BSN, RN]

i assume that you are asking how to rank these diagnoses by priority. i ranked them by maslow's hierarchy of needs for you. however, i do not understand what you mean by "give justification" for each one. i do see some problems with the related factors on some of these diagnoses--they do not all conform to the related factors listed by nanda. i also see that you do not have any evidence (symptoms) to support using ineffective airway clearance, impaired walking, or acute pain. you cannot pick nursing diagnoses without having the supporting evidence. is this the "justification" you refer to? evidence to support a diagnosis comes from what you observed in the patient.

1. impaired gas exchange related to hypoventilation as evidenced by dyspnea
   • hypoventilation cannot be a related factor for this diagnosis. the impairment of the gas exchange occurs in the alveoli of the lung and is either due to anatomical changes because of disease (as in emphysema) or blockages due to the presence of debris or exudate (as in pneumonia or asthma). does the patient have a respiratory disease that makes conditions in his lungs such that this condition exists?

[*]ineffective tissue perfusion (must specify the body system involved) related to impaired transport of oxygen across alveolar and/or capillary membrane as evidenced by dyspnea

• impaired transport of oxygen across an alveolar and/or capillary membrane is the same as impaired gas exchange. the only thing still missing is why.

[*]ineffective airway clearance related to mucous production

• everyone produces mucous. you must specifically say that there is excessive mucous production to use this diagnosis. ineffective airway clearance related to excessive mucous production as evidenced by [evidence of the patient's inability to clear secretions from their respiratory tract]

[*]activity intolerance related to imbalance between oxygen supply and demand

• you need evidence of the patient's inability to endure activities of daily living

[*]impaired walking secondary to slipped disk

• you need specific evidence of the kind of walking activity that the patient is unable to perform

[*]acute pain secondary to slipped disk

• you need specific evidence that the patient is having pain. when you are with a patient how do you know they are having pain?

[*]risk for falls related to presence of acute illness (hypertension)

• how does hypertension cause falls? i don't get the connection. that makes no sense to me.