Nursing diagnosis

Nursing Students LPN/LVN Students


How can something so simple give me such blues??? Can someone please help me; Not give me the answer but point me in the correct direction. So my case study is an 83 yr old male diagnosed with kidney failure and has been admitted for renal dialysis. Assesment: bp is 190/104, pulse bounding at 110 beats per minute, resp at 25 per minute, moist breath sounds, and 4+ pitting edema of the legs and ankles. He tells the nurse that he has gained 5 pounds during the last week and has had difficulty urinating.

NOW! I have to prioritize and come up with 3 NANDAS. I knw the abc's which are airway, breathing, and circulation. I also thought admittance was priority, keeping n mind his med diagnosis and admittance is upon renal failure. From the assessment, the vs may be regular for him because of his condition and age. I am also keeping in mind that he has moist breath sounds which can mean an ineffective breathing pattern (b of the abc's) BUT it isnt really the focused med dx. SO! Can i say priority 1 is ineffective breathing pattern related to moist breath sounds, 2- excessive fluid volume related to excess fluid retention, 3- dyspnea related to kidney failure OR should fluid retention be priority, then breath sounds then dyspnea??? AM I EVEN CLOSE to a reasonable solution??? Please help

Specializes in Complex pedi to LTC/SA & now a manager.

Dyspnea is not a nursing diagnosis but a medical diagnosis. Do you have a nursing diagnosis reference book that you are using?

Admittance--do you mean admitting diagnosis? I'm not familiar with the term admittance. Excessive fluid volume is accurate. Ineffective breathing pattern would include dyspnea, the rales/adventitious lung sounds ("wet breathing sounds") and the high RR. Your AEB would list the findings.

Personally, using your logic of the medical diagnosis the excessive fluid volume would be the priority as that is what is causing the breathing issues. Excessive Fluid Volume AEB hypertension, pitting edema, excessive rapid weight gain (5lbs in 7 days). Ineffective breathing pattern could be 2nd. For a third diagnosis, you can use a variety risk for electrolyte imbalance, risk for infection, risk for impaired skin integrity, impaired mobility/risk for impaired physical mobility, activity intolerance...

Using ABC or "what will kill you first" is often helpful in determining priority in nursing diagnosis but it is just as important to not over think the process.

Here's a useful website...

I am aware that dyspnea isnt a diagnosis. I said that wrong. I meant as far as at what point do i make it relevant enough to be placed for diagnosis. When i say admittance, i mean, i was taught that focusing on what a client is being admitted for is a priority as most cases. For instane, a client has come to er for abd pain, so why would i focus on a mole that could be on this paticular asignment we didnt have to do the usually comfortable with doing care plans because there is usually not a "wrong" answer. But prioritizing is a little different. Im learning though. thank you soooo much. Im enjoying the websites. Cant wait to get to

Specializes in Complex pedi to LTC/SA & now a manager.

Glad I could help... but yeah I'd go with your initial instinct that the priority diagnosis is the excessive fluid volume as that is the root cause of not only the hospitalization but also the breathing difficulties and other issues. So if I were submitting: 1. Excessive Fluid Volume, 2. Ineffective Breathing Pattern and probably 3. "Risk for impaired skin integrity" (as if the skin breaks down the risk for infection jumps exponentially).... Good thinking process there.

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