I need help with prioritization.

psu_213, BSN, RN · Mar 1, 2012

Good start so far. One other thing I see from his problem list...sleep apnea. This would lead to a risk dx, but an important one. When interviewing him ask him about it (treatments? CPAP? how well he sleeps?).

Liebchen · Mar 1, 2012

Yes indeed, it was very helpful. Thank you so much.

I am finding that my problem with this patient is so many problems, that I could write several DX on each problem. Then I get myself into trouble. Maslows hierarchy is very beneficial, thank you.

Oh, and I appreciate the links.

We followed this patient from the beginning of clinical to the end (ten weeks). I have 80 hours with him, and felt like I knew him very well. I read his chart daily, and did a head to toe daily and spent the rest of the day with him, learning and listening. I think this one patient has taught me more (as far as nursing DX goes) then my entire time in school.

Thanks to all of you for the dedication in helping the "babies" grow up to be real nurses. I appreciate you very much.

Esme12, ASN, BSN, RN · Mar 1, 2012

:hug:...YOU're welcome

MattNurse, MSN, RN · Mar 2, 2012

Cellulitis is an infection and treated as such, is the patient on antibiotics? I don't recall WBC count from prior posts, but I would take out Risk for infection and just write infection aeb Fever; Pain; tenderness in the affected area; Skin redness; inflammation;positive cultures; leukocytosis.

You might consider this order 1) infection, 2) fluid, 3) pain, 4) imbalanced nutrition, but I think your prioritization is 100% ok.

You won't solve the nutrition problem in an acute care setting so that is definitely belongs at the bottom in my opinion.

cayenne06, MSN, CNM · Mar 2, 2012

When I have trouble with prioritizing, I think it helps to look at the symptoms ("defining characteristics") instead of the medical dx. It doesn't tell you much just to know that your t has cellulitis, or CHF, or whatever. It is more useful to your plan of care to note the actual symptoms. This will quickly help you identify nursing diagnoses and prioritize your care to address the most alarming/urgent problems.

nurseprnRN, BSN, RN · Mar 2, 2012

no "risk for" infection-- that's what cellulitis is, an infection. he has one.

please correct me if i'm wrong, but it sounds as if you have started with his medical diagnoses and searched your mind for nursing diagnoses based on them.

many nursing students think there is a big list somewhere where column a is the medical diagnosis and column b is the nursing diagnosis. this is wrong-headed for several reasons. one is that nursing diagnoses are made by nurses using the nursing process (which i know you don't have a good handle on yet but we're trying to help), not dependent on a medical diagnostic process. nursing diagnosis is in no way subservient to or inferior to medical diagnosis.

yes, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.

for example, if i admit a 55-year-old with diabetes and heart disease, i recall what i know about dm pathophysiology. i'm pretty sure i will probably see a constellation of nursing diagnoses related to these effects, and i will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. i might find readiness to improve health status, or ineffective coping, or risk for falls, too. these are all things you often see in diabetics who come in with complications; there are others. they are all things that nursing treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. but i can't put them in any individual's plan for nursing care until *i* assess for the symptoms that indicate them, the defining characteristics of each.

does that help?

in your description of this patient i'm also seeing the possibility of hopelessness, loneliness, chronic low self-esteen, and compromised hunan dignity. i'm also seeing the possibility for ineffective coping, powerlessness, and ineffective health management; self-care deficit, self-neglect could be in the picture. all of these are nursing diagnoses, for which nursing prescribes interventions.

i found these by scanning the nanda headers; if you don't have the nanda 2012-2014 by now, that could be one reason you're having a hard time wrapping your head around nursing diagnosis.

yes, he has a renal problem; he has elevated creatinine.

Liebchen · Mar 3, 2012

Cellulitis is an infection and treated as such, is the patient on antibiotics? I don't recall WBC count from prior posts, but I would take out Risk for infection and just write infection aeb Fever; Pain; tenderness in the affected area; Skin redness; inflammation;positive cultures; leukocytosis.
You might consider this order 1) infection, 2) fluid, 3) pain, 4) imbalanced nutrition, but I think your prioritization is 100% ok.
You won't solve the nutrition problem in an acute care setting so that is definitely belongs at the bottom in my opinion.

Thank you. Yes, I don't know what I was thinking. Apparently I was not. I know it is an infection, as I have it in my presentation. It is those little things that I overlook, that makes me furious with myself. I took out the risk, which then makes more sense to make it priority.

Cayenne ~ I am trying to base it on his symptoms, problem is, he has so many, Edema, pain, Which is why I based his priority dx on his cellulitis. However, we are ( in our presentation) to look at the whole picture and include dx that would apply. I think I could come up with all of them just based on his cellulitis, and another dozen or so on his other problems. Thank you for your input. I appreciate it.

GrnTea~ I did change to infection and took the risk out. I actually was trying to diagnose based on his symptoms and presenting complaint, which was pain and cellulitis (severe). But if I can explain my rationale, perhaps that will explain why I came up with diagnosis.

I know he is in a lot of pain due to the infection. So, I thought if that was priority, taking care of infection would take care of pain. Then, if I took care of pain, that would ( as another poster suggested) would get his activity level up. Then of course, looking at the big picture, I felt it was necessary to address the excess fluid volume causing the edema. Which would help him to be more comfortable as well. Then I felt that addressing his nutrition, (long term facility, but not permanent, VA facility) would be beneficial in helping to keep the problem at bay... as far as keeping his diabetes in check and eventually, very long term, his weight. Although, as others has stated, I know that his weight will not be a priority in acute care setting. I do have the NANDA, and I use it all the time. But the NANDA does not help with prioritization. If I had a patient with just one issue, I don't think I would have all the issues I am having. But this patient has such a "cycle" of problems, that I am having a hard time addressing where to start in the cycle of prioritizing. Maslows theory was very helpful for me. It helped me to define importance, as far as "airway" or "pain".

Thank you, I find all of your suggestions and statements very helpful and a great learning experience.

Liebchen · Mar 3, 2012

Actually, his assessment is here:

patient presentation.pptx

Raewynv · Jun 8, 2012

I hate doing these. We are getting taught to separate problems into medical and nursing. (Medical are the ones that the docs diagnose and we can not do anything about. While nursing are the ones we can help with. Then into actual (which can be seen right now) and then into potential (Can happen). I am student a from New Zealand so our teaching may differ from yours